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Duplicate Reports:
Source Case Identifier
Linked Reports:
Report / Case Number
Reporter
Literature
Study
Study Registration

Sender

Receiver

Parent Medical History
MedDRA LLT Start Date Continuing End Date Comments
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Parent Past Drug Therapy
Drug Name MPID Version Date / Number Medicinal Product Identifier (MPID) PhPID Version Date / Number Pharmaceutical Product Identifier (PhPID) Start Date End Date Indication LLT Reaction LLT
Disease/Procedure LLT Start Date Continuing End Date Comments Family History
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Drug Name MPID Version Date / Number Medicinal Product Identifier (MPID) PhPID Version Date / Number Pharmaceutical Product Identifier (PhPID) Start Date End Date Indication LLT Reaction LLT
Reaction/Event reported Language of Report Reaction/Event reported in Native Language Reaction MedDRA LLT Reaction MedDRA PT Term Highlighted by Reporter Results in Death Life Threatening Caused / Prolonged Hospitalisation Disabling / Incapacitating Congenital Anomaly / Birth Defect Other Medically Important Condition Start date of Reaction/Event End date of Reaction/Event Duration of Reaction/Event Time interval between beginning of suspect drug administration and start of reaction/event Time interval between last dose and start of reaction/event Outcome of reaction/event at time of last observation Medical Confirmation by Healthcare Professional Identification of the Country Where the Reaction / Event Occurred
Test Date Test Name Test Name MedDRA LLT Test Result (code) Result (value / qualifier) Result Unit Result Unstructured Data (free text) Normal Low Range Normal High Range Comments (free text) More Information available
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Dosage Information Adding multiple rows of dosage information will cause the drug to be listed multiple times in the ICH R2 XML file
Active Subtance
Drug Recurrence
Indications for Use Adding multiple rows of indication will cause the drug to be listed multiple times in the ICH R2 XML file
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Document Name Document