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Non-Healthcare Professional

Reporter Information
(Your) Last Name
(Your) First Name
Occupation
Does Kelun-Biotech have permission to contact you about this report?
Phone number
E-mail address
Patient Information
Last Name
First Name
Gender
Patient Age
Date of Birth
Nation

Han

OtherNation
Weight
Height
Medical condition (diseases that are not recovered at the time of treatment)
Smoking history
Alcohol history
Pregnancy Status
Drug Information
Suspected drug (medicinal product considered by the reporter (e.g. physician, patient, etc.) as possibly related to the occurrence of the adverse reaction)
Product Name
Is the suspected drug a Kelun-Biotech product?
Drug Marketing Authorization Holder
Product Approval Number (e.g. 国药准字 HXXXXX)
Batch/Lot No
Single dose
Frequency (e.g. once daily, twice daily, etc.)
Route of administration (e.g., oral, intravenous drip, etc.)
Indication (fill in the indication for which the drug is used, e.g. hypertension)
Start and end date of drug
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Action taken with drug
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Concomitant Medications(Other medicines used concurrently by the patient at the time of the adverse reaction)
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Adverse Event
Adverse Event1
Adverse Event
Start date of the adverse event
End date of the adverse event
Outcome of the adverse event
Sequelae
Serious adverse event or not
Causality between the suspected drug (Kelun-Biotech product) and the adverse event provided by the reporter
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Please describe the adverse event(s) (including site of occurrence, symptoms, signs, clinical tests and treatments for events)
Attachments (product photos, diagnostics or other materials, formats of attachments allowed to be uploaded: jpg, jpeg, png, zip, rar, doc, docx, pdf, mp4, mp3, WAV)
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Additional information
Is the patient allergic to any medications, food or other products?
Other diagnosed illnesses / medical history / chronic health conditions:

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