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* 1. Enter your Name/ Names

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* 2. What is your gender?

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* 3. Your Phone Number

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* 4. What is your age?

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* 5. Name of drug/ Drugs taken or issued

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

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

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* 8. Severity of the reaction

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* 9. Action taken

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* 10. Outcome (What was the outcome) ?

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