* 1. Enter your Name/ Names

* 2. What is your gender?

* 3. Your Phone Number

* 4. What is your age?

* 5. Name of drug/ Drugs taken or issued

* 6. Other drug / Drugs  taken 3 months prior to reaction

* 7. Name of facility or doctor where drug was issued and their Physical location or address

* 8. Severity of the reaction

* 9. Action taken

* 10. Outcome (What was the outcome) ?

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