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1. Patient details:

Name :*

Date of Birth:

Age (Years):*

Height(cm) :

Weigh(KG) :

Sex*

Country *

City*

Phone no*

2. Reaction Information

Reactions Start: *

Reactions End: *

Please Describe the Reaction:*

In case of adverse reaction Check all appropriate:*
Patient diedInvolved or prolonged inpatient hospitalizationInvolved persistence or significant disability or incapacityLife threateningCongenital abnormalities

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?*
YesNo

Did reaction reappear after reintroduction of drug?*
YesNo

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 :*

Specialty:*

Phone no. :*

Address:*

Email :*

Attach file:

test

1. Patient details:

2. Reaction Information

3. Suspected Drug(s) Information

4. Reporter’s Details

1. Patient details:

2. Reaction Information

3. Suspected Drug(s) Information

4. Reporter’s Details

1.بيانات المريض:

2. بيانات الأثر الجانبى:

3. بيانات الدواء المشتبه به:

4. بيانات المبلغ: