Genologix Adverse Drug Reaction Form FAQ ADR Form Initials * Surname * Age Are You Pregnant? Yes No Race Weight (kg) Height (cm) Allergies Suspected Medicine (Medicine to Have Caused an ADR) Trade Name (Suspected Medicine 1) Administration Route Dosage (mg) & Interval Date Started Date Stopped Reason for Use Batch Number Expiry Date Section Buttons Suspected Medicine (Medicine to Have Caused an ADR) Complete Only if You Suspect More than 1 Genologix Medicine is Responsible for Reaction Trade Name (Suspected Medicine 2) Administration Route Dosage (mg) & Interval Date Started Date Stopped Reason for Use Batch Number Expiry Date Section Buttons Suspected Medicine (Medicine to Have Caused an ADR) Complete Only if You Suspect More than 1 Genologix Medicine is Responsible for Reaction Trade Name (Suspected Medicine 3) Administration Route Dosage (mg) & Interval Date Started Date Stopped Reason for Use Batch Number Expiry Date Section Buttons Adverse Drug Reaction/Product Quality Problem Date of Onset Time of Onset Date Reaction Resolved Please Describe Adverse Reaction/Product Quality Problem. Include as much Clinical Information as Possible Complete Only if You Were Taking Other Medicines at the Time of Reaction Other Medicine Customer Was Taking at the Time of Reaction (Including Herbal Medicines) Trade Name (Other Medicine 1) Administration Route Dosage (mg) & Interval Date Started Date Stopped Reason for Use Batch Number Expiry Date Section Buttons Other Medicine Customer Was Taking at the Time of Reaction (Including Herbal Medicines) Trade Name (Other Medicine 2) Administration Route Dosage (mg) & Interval Date Started Date Stopped Reason for Use Batch Number Expiry Date Section Buttons Other Medicine Customer Was Taking at the Time of Reaction (Including Herbal Medicines) Trade Name (Other Medicine 3) Administration Route Dosage (mg) & Interval Date Started Date Stopped Reason for Use Batch Number Expiry Date Section Buttons Other Medicine Customer Was Taking at the Time of Reaction (Including Herbal Medicines) Trade Name (Other Medicine 4) Administration Route Dosage (mg) & Interval Date Started Date Stopped Reason for Use Batch Number Expiry Date Section Buttons Other Medicine Customer Was Taking at the Time of Reaction (Including Herbal Medicines) Trade Name (Other Medicine 5) Administration Route Dosage (mg) & Interval Date Started Date Stopped Reason for Use Batch Number Expiry Date Section Buttons Other Medicine Customer Was Taking at the Time of Reaction (Including Herbal Medicines) Trade Name (Other Medicine 6) Administration Route Dosage (mg) & Interval Date Started Date Stopped Reason for Use Batch Number Expiry Date Section Buttons Submit If you are human, leave this field blank.
