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Drug Name:
State the start date of medication, including dosage strength and frequency (e.g., 60 mg, three times daily). Describe any medical measures taken (such as dose reduction or drug discontinuation) and their impact on the adverse event.
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Drug-related Adverse Events:
Describe changes in symptoms over time. Detail any treatments administered for the adverse event. Provide the name and contact information of the healthcare professional who managed the treatment.
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Your Personal Information (Optional):
Please note that your personal identifiable information (such as name, email address and phone number) will not be shared. Qingfeng Pharmaceutical or its agents may contact you for further details about the adverse event. If you do not wish to be contacted, please indicate this in your email.
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Information of the Person Experiencing the Adverse Event:
Current medical condition. All ongoing medications (name, dosage strength, frequency and start date). Gender and age of the patient (optional).
