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English Report

Reporting of Adverse Events

    1. Patient details:

    Name :*

    Date of Birth:

    Age (Years):*

    Height(cm) :

    Weigh(KG) :


    Country *


    Phone no*

    2. Reaction Information

    Reactions Start: *

    Reactions End: *

    Please Describe the Reaction:*

    In case of adverse reaction Check all appropriate:*

    Outcome of the event:*

    Treatment Given for reaction:*

    3. Suspected Drug(s) Information

    Suspect drug(s) name including generic name and batch no.(If Applicable):*

    Daily dose(s): *

    Route of administration: *

    Indication for use: *

    Therapy dates:

    From: *

    To: *

    Did reaction disappear after stopping drug?*

    Did reaction reappear after reintroduction of drug?*

    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 ofperiod, etc.):*

    4. Reporter’s Details

    Name :*


    Phone no. :*


    Email :*

    Attach file:

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