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Report Adverse Reaction

Pharma-Tech

Pharmacovigilance

Department

ADVERSE DRUG REACTIONS REPORTING FORM


A. Patient Details

Name/Initials:

Sex:

Age/Age group:

Weight: kg

B. Reporter Details (The one supplying the information for this report)

Name:

Address:

Telephone/Mobile:

E-mail:

Reporter’s Identity:

Date of reporting: (dd/mm/yyyy)

C. Suspected Drug(s)

Drug Name (trade name and generic)

Concentration

Dose

Route of administration

Indication

Date started

Date stopped

Batch number

D. Adverse Drug Reaction (ADR) Description

Description

Date ADR started

Date ADR stopped

Did the patient stop the suspected drug?


If Yes,

Did the ADR stop after stopping the drug?

 

Did the ADR reappear after retaking the drug?


 

Management of ADR (If any):


Outcome after management:

E. Seriousness of the Adverse Drug Reaction

Is the ADR serious (based on the reasons below)?


If yes, please select the reson:






 

 

 

 

 

 

 

 

F. Relevant Medical History/ preexisting medical conditions (please include allergies, pregnancy, smoking and alcohol use, hepatic/renal dysfunction, etc.)

G. List of other drugs taken (please list all other drugs taken the last month prior to the ADR excluding the suspected drug(s))

Drug Name

Concentration

Dose

Route of administration

Indication

Date started

Date stopped

Comments:


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Tel/Fax : +202 26701089/95

Mobile: 01015158808

E-mail : info@pharmatech.com.eg

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18, Al Lewaa Mahmoud Samy St., of Kaboul St., Makram Obeid, Nasr City, Cairo, Egypt
Telephone: (+20) 2 670 10 89 / 95
Fax: (+20) 2 670 10 89 / 95

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