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Healthcare Professionals

I. PARTICULARS OF PATIENT
Other relevant information: e.g. medical history, allergies, pregnancy, smoking, alcohol use, etc. Please enclose any relevant laboratory results including dates (if done)
III. DETAILS OF SUSPECTED DRUG(S) AND ALL OTHER DRUGS USED

(Please specify brand name if known)

(including complementary drugs, herbal medicines consumed at the same time and or 3months before)

IV. MANAGEMENT OF ADVERSE REACTION.
V. REPORTER DETAILS:
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