1. Full Name
2. Weight
3. Age
5. Country
6. State/Province
7. Description of Adverse Event
8. Relevant Diagnostic Tests
9. Underlying Disease and Relevant Medical Conditions
10. Concomitant Medication
12. Generic Name
13. Brand Name
14. Route of Administration
15. Dose
16. Batch/Lot Number
17. Start Date of Treatment (Day/Month/Year)
18. End Date of Treatment (Day/Month/Year)
19. Indication for Use
20. Expiration Date (Day/Month/Year)
23. Event Start Date (Day/Month/Year)
24. Report Date (Day/Month/Year)
25. Full Name
26. Workplace
27. Address
28. Profession
29. Phone Number
30. Email