Name: {{name}}
Address: {{address}}
City: {{city}}
State: {{state}}
Zip: {{zip}}
Phone: {{phone}}
Email: {{email}}

Patient Information

*Date of birth: {{date_of_birth}}
*Sex: {{sex}}
*Weight (lbs): {{weight}}

Adverse Event or Problem

*Describe event: {{event_or_problem}}
*Outcomes attributed to adverse event (check all that apply): {{outcome_death}}
{{outcome_threat}}
{{outcome_hospital}}
{{outcome_disability}}
{{outcome_anomaly}}
{{outcome_intervention}}
{{outcome_other}}
*Date of event: {{event_date}}
*Describe event or problem: {{event_description}}
*Other relevant history such as preexisting medical conditions: {{relevant_history}}

Suspect Medication(s)

*Name of medication (give labeled strength if known): {{medication_name}}
{{medicine_other}}
*Dosage & frequency used: {{dose_frequency}}
*Therapy dates: {{therapy_date_from}} to {{therapy_date_to}}
*Diagnosis for use: {{indicated_use}}
*Event ended after use stopped or dose reduced: {{stopped_after_use}}
*Medication Lot #
(if known):		 {{lotnum}}
*Event reappeared after reintroduction: {{reappeared_after_reintro}}
*Other medications and therapy dates: {{other_medications}}