Patient Safety & Pharmacovigilance

Patient Information

Source*

Physician

Nurse

Pharmacist

Consumer

Initials*

First Name*

Last Name*

Email ID*

Confirm Email ID*

Contact No*

Address*

Street Address*

Country*

State/Province/Region*

City*

Postal Code*

Physical Details

Weight(kg)*

Height(cm)*

Date of Birth*

Sex*

Male

Female

Other

Adverse Event

Description of Adverse Event*

Event Onset Date*

Event Stop Date*

Treatment Received*

If yes, Specify Received Treatment*

Outcome of Adverse Event*

Recovered

Recovered with Sequelae

Not Recovered

Unknown

Medical History

Current or Past Relevant Medical History*

Yes

No

(Incl. concurrent illness, allergy, smoking, alcohol abuse)

Lab Tests & Findings

Suspect Drug Name and Strength*

Dose & Frequency*

Routes*

Therapy Start Date*

Therapy Stop Date*

Batch Details*

Indicates of Use*

Treatment Received*

Laboratory Tests & Findings Relevant to the Adverse Event* Accepted file types : jpg, png, pdf, Max. file size: 1MB.

Proof of Side Effect* Accepted file types : jpg, png, pdf, Max. file size: 1MB.

Other Medication

Medication taken during the past 3 months prior to the event?*

Yes

No

Consent to be contacted*

Yes

No

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