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DRUG NAME

MANUFACTURER NAME

DRUG INDICATION

EVENT DESCRIPTION


OUTCOME CODE
Death Life-Threatening Hospitalization Disability Congenital Anomaly Required Intervention Other

DRUG'S ROLE CODE
Primary Suspect Secondary Suspect Concomitant Interacting

PATIENT GENDER
Unknown Male Female Not Specified

REPORTER'S OCCUPATION
Physician Pharmacist Other health professional Lawyer Consumer

PATIENT MASS - kg


PATIENT AGE - years



REPORT DATE


MANUFACTURER RECEIPT DATE


FDA RECEIPT DATE