REPORT ADVERSE EVENTS

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Reporter Information *Name : *Phone number : Date : *Occupation : Address :
Patient Details *Name : Age : Weight : sex : Pregnant : Address : *Phone number : Suspected reaction(s) : Please describe the reaction(s) and any treatment given Date reaction(s) started : Duration of the reaction(s) Patient history of any reaction including allergies : Patient medical history : Did the reaction(s) improve when the drug was discontinued : Did the reaction(s) reappear when the drug was readministered : Outcome : Did the reaction(s) lead to hospitalization : Paraclinical findings related to the reaction(s) :
Suspected medicine(s):
Medicine Dosage form & potency Daily dosage Route Indication Date started Date discontinued Manufacturer Batch No Date started Remove
ADD Suspected medicine
Medications taken at the time of ADR:
Medicine Dosage form & potency Daily dosage Route Indication Date started Date discontinued Manufacturer Batch No Date started Remove
ADD Medications taken at the time of ADR
 

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