Pharmacovigilance Report

Adverse Event Reporting Form

Full Name Gender

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 (Full Name) Indicated medicine above is the probable cause Medicine Producer (Manufacturer or Distributor) Batch Number or Lot Number Dosage 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

Data Privacy Consent

Adverse Event Reporting Form