Natural Medicines - Natural MedWatch

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9.	Adverse Event Details	Adverse Event Info

	Check all outcomes that apply to this adverse event: Death (enter date: MM/DD/YY) Life-threatening Hospitalization, either initial or prolonged Medical intervention required Disability or permanent damage Congenital birth defect or anomaly Other serious event

	Date of the event: (MM/DD/YY)

	Describe the Adverse Event:


10.	List any relevant laboratory data (e.g., liver function tests, renal function, WBCs, etc):


11.	Did the symptoms resolve when the product was discontinued? Yes No N/A

	Comments:

12.	If the product was taken again, did the adverse event occur a second time? Yes No N/A

	Comments:


To report an adverse event or side effect related to a natural medicine, complete the form below. Your report will improve healthcare by aiding researchers and will be forwarded to the appropriate regulatory agency…such as the Food and Drug Administration. If you have any questions, see our Frequently Asked Questions (FAQ) or learn more about Natural MedWatch.