Pharmacovigilance

Patient Initials *

Date of birth *

Age *

Gender *

Country *

Reaction onset *

Check all appropriate to adverse reaction *

Patient died

Involved or prolonged inpatient hospitalization

Involved persistence/significance/ disability or incapacity

Life threatening

Congenital anomaly

Other medically important condition

Suspect drug(s) information *

Did reaction abate after stopping drug? *

Yes

No

N/A

Did reaction reappear after reintroduction? *

Yes

No

N/A

Therapy dates *

Health-care provider *

Pharmacist

Physician

Patient

Others

Manufacturer’s information *

Date received by manufacturer

Date of this report

Report type *

Initial

Follow Up

Your Email *

Subject *

Separate email addresses with a comma.

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