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On Centre-Pharmacovigilance Programme of India) Ministry of Health & Family Welfare Government of India Sector-23, Raj Nagar, Ghaziabad-201002 www.ipc.nic.in A. PATIENT INFORMATION AMC Report No. Worldwide Unique 12. Relevant tests / laboratory data with dates 2. Age at time 3. Sex M F of Event or date of birth 4. Weight Kgs 1.Patient Initials 13. Other relevant history including pre-existing medical conditions (e.g. allergies, race, pregnancy, smoking, alcohol us.

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