Category Of Reporting Person *Please select an option---DOCTORPATIENTPHARMACISTPHARMACOLOGISTNURSERESEARCHERPATIENT RELATIVEOTHERSName Of Reporting Person * *QualificationCity /State / RegionMobile * *Email * *Patient Name * *Age *Weight *Gender * *Please select an option---MaleFemaleBrand Name * *Enter Generic Name * *Dosage Form * *Please select an option---TABLETCAPSULELIQUIDOINTMENTCREAMGELLOTIONINJECTIONSPRAYOTHERSBatch NoManufacturing DateMarketed ByDose and Duration of Medicine UsedApproximate Date/Month/Year, when Medicine was used (may be back-date)(Please write, what side effects were observed) * *(See list of various side effects / adverse reactions, a drug may create)Additional /Concomitant Medicine Used , If AnyOther relevant history (eg. allergy, pregnancy, renal / hepatic dysfunction, diabetes, thyroid etc.) Also please indicate if undergone any major surgical / medical treatmentSeriousness of reaction / side effect :- Whether side effect reduced/vanished/remained after discontinuation of the medicine(s)Remark ,If AnySubmit
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