Name:
Phone / Mobile:
Profession:
Email:
Place of Practice:
Address of Practice:
Date of the Report:
Additional Information or Notes (if there):
Patient Initial:
Age:
Weight:
Height:
Gender: MaleFemale
Pregnancy: NoYes
week:
Generic Name:
Scientific Name:
Daily Dose:
Indication:
Batch Number:
Date:
Adverse Event Onset Date:
Describe the Reaction:
Did Reaction Disappear?
YesNoDon’t Know
Did Reaction Reappear After Reintroduction of Drug?
Patient Status
RecoveredRecoveringNot recoveredUnknown
Tick appropriate box with reference to the adverse drug reaction (if applicable):
Require hospitalizationProlonged hospitalizationLife threateningCongenital anomalyRequired intervention to prevent permanent impairment / damagePermanent disabilityDeathOther
Death Date:
Other:
Action Taken With Suspect Drug
Discontinued due to AEDose increasedDose decreasedNoneOther (please specify)
Concomitant drugs (exclude drugs used to treat reaction) and medical history any diseases that the patient has (for example: Diabetes,Hypertension, etc...)
Drug Name:
From:
To:
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