患者或報(bào)告人聯(lián)系方式/Patient or Report PhoneNumber
藥品名稱/Drug Name *
批準(zhǔn)文號/Approval Number
用藥原因/Medical Reasons
不良反應(yīng)/Adverse Reactions *
用藥及不良反應(yīng)過程描述/Medication and Description Of AdverseReactionProcess