Suspected Adverse Drug Reaction Reporting Form
[[[[“field35″,”equal_to”,”Yes”]],[[“show_fields”,”field47″]],”and”],[[[“field47″,”contains”,”Other”]],[[“show_fields”,”field62″]],”and”],[[[“field93″,”equal_to”,”Yes”]],[[“show_fields”,”field109,field110,field107,field84,field105,field14,field80,field101,field17,field100,field99,field98,field74,field70,field95,field73″]],”and”],[[[“field73″,”equal_to”,”Yes”]],[[“show_fields”,”field66,field9,field10,field108,field13,field106,field104,field79,field103,field77,field76,field65,field97,field96,field58,field113″]],”and”],[[[“field113″,”equal_to”,”Yes”]],[[“show_fields”,”field114,field115,field116,field117,field118,field119,field120,field121,field122,field123,field124,field125,field126,field127,field128,field129″]],”and”],[[[“field129″,”equal_to”,”Yes”]],[[“show_fields”,”field144,field143,field142,field141,field140,field139,field138,field137,field136,field135,field134,field133,field132,field131,field130″]],”and”],[[[“field47″,”equal_to”,”Death”]],[[“show_fields”,”field182″]],”and”],[[[“field145″,”equal_to”,”Yes”]],[[“show_fields”,”field161,field160,field159,field158,field157,field156,field162,field163″]],”and”],[[[“field163″,”equal_to”,”Yes”]],[[“show_fields”,”field180,field179,field178,field177,field176,field175,field174,field181″]],”and”],[[[“field181″,”equal_to”,”Yes”]],[[“show_fields”,”field185,field186,field187,field188,field189,field190,field191,field192″]],”and”],[[[“field192″,”equal_to”,”Yes”]],[[“show_fields”,”field199,field198,field197,field196,field195,field194,field193″]],”and”],[[[“field47″,”equal_to”,”Other”]],[[“show_fields”,”field62″]],”and”]]
1 A. Patient Information
2 B. Suspected Adverse Reaction
3 C. Suspected Medication(S)
4 D. Reporter Details
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*Mandatory data to be filled