SUSPECT ADVERSE REACTION REPORT

SUSPECT ADVERSE REACTION REPORT

I.REACTION INFORMATION

8-12. CHECK ALL APPROPRIATE TO ADVERSE

II. SUSPECT DRUG(S)  INFORMATION

21. DID REACTION ABAT E AFTER REINTRODUCTION

III. CONCOMITANT DRUGS AND HISTORY

IV. MANUFACTURER INFORMATION

24d. REPORT SOURCE

25a. REPORT TYPE ADMINISTRATION

20. DID REACTION ABATE AFTER STOPPING DRUG

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