Suspected Adverse Events Reporting Form

User of the medicine

Sex MaleFemaleUnknown

Lactating Pregnant

Weight (kg)

Date of Birth

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Age at time of reaction

Country where reaction started

City Name

Describe what happened

Describe what happened in your own words, any symptoms or side effects you suspect were caused by your medicine, and what happened since then. Other specific details about each medicine and relevant dates can be entered below.

Description

Describe the reactions in your own words. Click 'Add another reaction/symptom' for each reaction you will describe.

Reaction / Symptom

Start Date

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End Date

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Duration

Outcome of reaction

Is the reaction serious? YesNo

Reason for seriousness Life threateningDeathCaused/prolonged hospitalisationDisabling/incapacitatingCongenital anomaly/birth defectOther medically important condition

Please provide comments

Medicine Details

Enter the name and details for each medicine you were taking before the reaction occurred. Click "Add another medicine" for each new medicine. Please also include herbal preparations, recreational drugs, or other alternative medicines.

Medicine Name

Medicine Producer

Batch Number

Dosage

How much did you take? e.g. 2 tablets 50 mg, 3 times a day

How was the medicine administered

other route of administration does not mention above

Start Date

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End Date

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Reason for taking medicine

Action taken with medicine

Additional Information

Current and previous illnesses

Please give a short description of your medical history. This is important since some reactions only appear with a combination of previous or ongoing disease, special diets, recreational drugs, smoking habits, alcohol intake or allergies.

Additional comments

Contact Details

Profession of the Reporter

Other profession

Reporter name

Patient name

Workplace name

Email

Telephone

Send Email receipt