Report Side Effects Form (for Professionals)

Dear healthcare professional;

We realize that filling this form requires time to complete, but reporting adverse drug reactions are indispensable for safe use of medication. be sure reporter’s and patient’s identity are held in strict confidence by the company and protected to the fullest extent of the law, information provided by the reporter will be strictly protected and will not be used in any way against him her.

This form can be used by: Physician, Pharmacist, Dentist, Nurses and Other healthcare providers.

Please fill the form carefully:

Patient details

Patient name or initial:

Age(in Years)

Sex *

Female
Male

Date of birth *

Weight(Kg)

Height(cm)

Suspected & Concomitant Drug(s) Used

Product name: *

Concomitant drug name:

Adverse Drug Reaction

Describe The Adverse Reaction Including Relevant Tests/Lab Data and Dates(Describe The Adverse Reaction Including Relevant Tests/Lab Data and Dates(exclude those used to treat reaction) *

Illustrate All Other Relevant History, Including Preexisting Medical Conditions (diagnosis, allergies, pregnancy, hepatic, renal etc)

Date of event started:

Date of event disappeared, ( if applicable):

Outcome of ADR (Tick all applicable)

Event disappeared after stopping (DE challenge)

Yes
No
Unknown

Event reappear after reintroducing (Rechallenge)

Yes
No
Unknown

Specific antagonist or treatment used

Yes, specify
No

Action Taken

Seriousness of ADR (Tick all applicable)

Reporter Details

Reporter name *

Profession (Specialty) *

Country

Address

Phone *

Email *