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Side Effects Reporting
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Side Effects Reporting
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Patient Details
Name
*
Date of Birth
Age (Years)
*
Sex
*
Male
Female
Government
*
Alexandria
Aswan
Asyut
Beheira
Beni Suef
Cairo
Dakahlia
Damietta
Faiyum
Gharbia
Giza
Ismailia
Kafr El Sheikh
Luxor
Matruh
Minya
Monufia
New Valley
North Sinai
Port Said
Qalyubia
Qena
Red Sea
Sharqia
Sohag
South Sinai
Suez
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
Suspected Drug(s) Information
Suspect drug(s) name (including generic name and batch no.)
*
Daily dose(s)
Selected Value:
1
Route of administration
Indication for use
Therapy Dates
From
*
To
*
Therapy duration
Did reaction abate after stopping drug?
*
Yes
No
Did reaction appear after reintroduction of drug?
*
Yes
No
NA
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.)
Reporter’s Details
Name
*
Reporter Name
Specialty
*
Reporter's Specialty
Tel. no.
*
Reporter's Phone Number
Address
*
Reporter's Address
Email
*
Reporter's Email
Submit
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