简 EN 繁
简 EN 繁

Please enter the information you want to find

Hot key words：
Hyaluronidase xxx

Welcome to the Adverse Reaction/Event Form

If you or you become aware that other patients have experienced or are experiencing adverse events after using Baoji products, you should promptly seek advice from healthcare professionals and fill out the adverse event report form according to the following steps

Last Name *

Qualification *

Please choose

Organisation

Phone *

E-Mail *

Do you agree to follow-up

Yes
No

Organisation: If you are a Health Professional

Next step Return

Last Name

Gender *

Please choose

Date of birth

Phone

Nationality

Ethnicity/Race

Weight (kg)

Height (CM)

Pre-existing disease

Next step Return

Product *

Market Authorization Holder *

Batch/Lot

Frequency

Single Dosage

First Dose *

Action(s) Taken with Drug

Please choose

Last Dose

Other concomitant medications

Next step Return

AE Term *

Onset Date *

Outcome *

Please select

Adverse Reaction Resolution Date

Causality Assessment *

Please select

Narrative*

AE Term：Clinical diagnosis preferred; if none, specify main symptoms

Adverse Reaction Resolution Date: leave blank if ongoing

Narrative: Please provide as much detail as possible, including the patient's medical history, allergy history, medication information, diagnosis and treatment of adverse reactions, lab test results, pregnancy and breastfeeding, etc.

Next Back

Upload relevant documents (patient medical records, lab test reports, and other attachments may be inserted here)

Return