Merz Adverse Event Merz Adverse Event I. EVENT INFORMATION 1. Patient Initials (first, last) * 1a. Country * 2. Date of Birth * 2a. Age 3. Sex * Female Male 4-6. Reaction Onset * 7-13. Describe Reactions * Indicate All Propriate To Adverse Event * Patient died Involved or prolonged hospitalisation Involved persistent or significant disability or incapacity Life threathening Congenital anomaly Other medical important condition Upload Documentation Upload file here Choose File Maximum upload size: 516MB II. SUSPECT DRUG(S) INFORMATION 15. Daily Dose(s) * 14. Suspect Drug(s) * Det her er en beskrivelse på et felt 16. Route(s) of Administration * 17. Indication(s) For Use * 18. Therapy Date (from) * 18. Therapy Date (to) * 19. Theraphy Duration * 20. Did Reaction Abate After Stopping Drug? * YES NO UK NA 21. Did Reaction Reappear After Reintroduction? * Yes No UK NA III. CONCOMITANT DRUG(S) AND HISTORY 22. Concomitant Drug(s) and Dates of Administration * *Exclude those used to treat reaction 23. Other Relevant History * IV. MANUFACTURER INFORMATION 24a. Name and Address of The Company Managing Case * 24b. Original Report Number * 24c. Date of Receipt * 24d. Date of this Report * 25a. Report Type Initial Follow-up 25b. Report Source Study Consumer Report Health Professional Literature Regulatory Auhtority Other 26. Name and Address of Reporter (Include Zip Code) * Reporter Email * If you are human, leave this field blank. Submit
