Temple of Herbs

Product Name * Enter the exact name of the product you were taking

Batch Number * Check the bottle label for batch/lot number

Purchase Date * When did you purchase this product?

Date First Used When did you first start taking this product?

Dosage Taken How much were you taking and how often?

Describe Your Symptoms * Be as specific as possible about what you experienced

Severity Level * How severe were your symptoms?

When Did Symptoms Start? * Date and time symptoms first appeared

How Long Did Symptoms Last? Duration of symptoms

Medical Treatment Received? What medical care did you seek?

Age * Your age at time of reaction

Gender Optional

Current Medications & Supplements Include prescription drugs, over-the-counter medications, and other supplements

Known Allergies Food, drug, or environmental allergies

Medical Conditions Relevant health conditions

I am currently pregnant

I am currently nursing/breastfeeding

Email Address * We'll use this to follow up on your report

Phone Number Optional - for urgent follow-up if needed

Preferred Contact Method How would you prefer we contact you?

Additional Notes Timeline of events, other products used, etc.

I consent to Temple of Herbs contacting me regarding this adverse event report for follow-up questions and updates on the investigation.

I consent to sharing relevant information from this report with the FDA and other regulatory agencies as required by law.

Important: By submitting this report, you acknowledge that you have provided accurate and complete information to the best of your knowledge.

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