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: M Pregnant: Yes (DD/MM/YYYY) Adverse Event Product Problem (e.g., defects/malfunctions) No Other relevant history including pre-existing medical conditions (e.g. allergies, smoking, alcohol use, hepatic/ renal dysfunction etc.): B. ADR Details ADR term(s): Date reaction(s) started: (DD/MM/YYYY) Date reaction(s) Stopped: (DD/MM/YYYY) Description of adverse events: (including sign and symptoms with specific Death (DD/MM/YYYY) diagnosis, treatment and a.

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