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Visitors Portal
Pharmacovigilance
Adverse Effect Reporting Forms
Please Fill The Form Below To Report Any Adverse Effects.
Pharmacovigilance Form
(A) Patient Details
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Name On Folder
*
Name On Folder
First
First
Last
Last
Age of Patient
Date of Birth
Gender
Male
Female
Body Weight (KG)
Phone Number
Hospital/Treatment Center
(B) Details of Adverse Reaction & Any Treatment Given
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Please Give Details
Date Reaction Started
*
Date Reaction Stopped
*
(C) Outcome of Adverse Reaction
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What Was The Outcome
*
Recovered
Not Yet Recovered
Unknown
Did The Adverse Reaction Result In Any Untoward Medical Condition?
*
Yes
If Yes Please Specify
If Yes Please Specify
No
Seriousness
*
Death
Life Threatening
Disability
Hospitalization
Others (Please Specify)
Others (Please Specify)
(D) Suspected Product (s)
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Brand Name
*
Generic Name
Batch Number
*
Expiry Date
Manufacturer
*
Reasons For Use (Indication)
*
Daily Dose
*
Route of Administration
*
Date Started
Date Stopped
Did The Adverse Reaction Subside When The Drug Was Stooped (De-Challenge)?
*
Yes
No
Was The Product Prescribed?
*
Yes
No
Source Of Drug
Was a product re-used after detection of adverse effect (re-challenge)?
Yes
No
Did adverse effect reaction re-appear upon re-use?
Yes
No
(E) Concomitant Including Herbal Medicines Taken Prior To Adverse Reaction
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Give details
Attach All Relevant Laboratory Test/Data
Drop a file here or click to upload
Choose File
Maximum file size: 516MB
(F) Reporter Details
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Name of Reporter
*
Name of Reporter
First
First
Last
Last
Profession
*
Address
Address
Address
Address
City
City
State/Province
State/Province
Zip/Postal
Zip/Postal
Email
Phone Number
*
Date
Submit
If you are human, leave this field blank.
