Adverse Reaction Collection Form-Hunan Chunguang Jiuhui Modern Chinese Medicine Co., Ltd.

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Adverse Reaction Collection Form

Medicine	Product Name	Product Type	Manufacturing Enterprise	Batch Number	Usage and Dosage (Dosage and frequency of administration)	Starting and ending time of medication
Suspected drugs						-
Concomitant medication						- - -

The infusion referred to in this column is the separated liquid, such as injection solution and infusion solution, that is used concurrently with the suspected drug and may be related to this adverse reaction.

Medicine	Product Name	Product Type	Manufacturing enterprise	Batch Number	Usage and Dosage (Dosage and frequency per day)	Starting and ending time of medication
Suspected drugs						-
Concomitant medication						-

The infusion referred to in this column is the separated liquid, such as injection solution or infusion solution, that is used concurrently with the suspected drug and may be related to this adverse reaction.

Description and handling of the group adverse reaction process (may be attached):

Please upload a file in PDF or ZIP format