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Side Effects Reporting EN
Patient Info
Reaction Info
Suspected Drug(s) Info
Therapy Dates
Concomitant drug(s) and history
Reporter's Details
Patient Information:
Name
Date of Birth
Age (Years)
Sex
- Select -
Male
Female
Government
- Select -
Cairo
Giza
Alexandria
Qalyubia
Beheira
Dakahlia
Sharqia
Gharbia
Monufia
Kafr El Sheikh
Damietta
Port Said
Ismailia
Suez
North Sinai
South Sinai
Beni Suef
Fayoum
Minya
Assiut
Sohag
Qena
Luxor
Aswan
Red Sea
New Valley
Matrouh
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Reaction Information:
Reaction onset
Describe the Reaction
Check all appropriate to adverse reaction:
Patient died
Involved or prolonged inpatient hospitalization
Involved persistence or significant disability or incapacity
Life threatening
Congenital abnormalities
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Next
Suspected Drug(s) Information:
Suspect drug(s) name (including generic name and batch no.)
Suspect drug(s) name (including generic name and batch no.)
0
Route of administration
Indication for use
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Therapy Dates:
From (Date)
To (Date)
Therapy duration
Did reaction abate after stopping drug?
Yes
No
Did reaction appear after reintroduction of drug?
Yes
No
NA
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Next
Concomitant drug(s) and history:
Concomitant drug(s) and dates of administration (exclude those used to treat reaction)
Other relevant history (e.g. Diagnostics, allergies, pregnancy with last month of period, etc.)
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Next
Reporter’s Details:
Reporter Name
Specialty
Mobile
Address
Email
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