Pharmacovigilance Reporting Form
In compliance with the Data Privacy Act of 2012 (RA 10173), all personal information collected will be kept strictly confidential for pharmacovigilance purposes.
Full Name
Gender
Select
Male
Female
Date of Birth
Age at the time of reaction
Country where the reaction started
Description of Reaction
Reaction/Symptoms present
Start Date of Reaction
End Date of Reaction
Duration (How many days?)
Outcome of reaction
Medicine Name (Indicate the full name of Medicine)
Indicated medicine above is the probable cause
Select
Yes
No
Medicine Producer (Manufacturer or Distributor)
Batch Number or Lot Number
Dosage (How much medicine did you take? Ex: 2 tablets 50mg, 3 times a day)
How was the medicine taken or administered?
Start date of when medicine was taken
End date of when medicine was taken
How long was the medicine taken (How many days?)
Action taken with medicine
Current and previous illnesses
Additional comments
ATTENDING PHYSICIAN
Profession
Given
Family Name
Health facility (Optional)
Email
Telephone / Mobile Number
Another Medicine Taken together with the Reported Drug
Submit Report
