Report Adverse Reaction

Pharma-Tech

Pharmacovigilance

A. Patient Details

Name/Initials:

Sex: MaleFemale

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: PhysicianPharmacistNursePatientOther

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

Did the patient stop the suspected drug? YesNoDon’t know

If Yes,

Did the ADR stop after stopping the drug? YesNoDon’t know

Did the ADR reappear after retaking the drug? YesNoDon’t knowDid not retake the drug

Management of ADR (If any):

Outcome after management: RecoveredRecoveringNo improvementUnknown

E. Seriousness of the Adverse Drug Reaction
Is the ADR serious (based on the reasons below)? YesNo If yes, please select the reson: Death Life threatening Hospitalization Prolonged hospitalization Permanent disability Congenital anomaly Required intervention to prevent damagen Other
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))

Comments:

18, Al lewaa Mahmoud Samy st., from Kaboul st., Makram Ebeid, Nasr City, Cairo, Egypt.

Tel/Fax : +202 26701089/95

Mobile: 01015158808

E-mail : info@pharmatech.com.eg

Click on one of our products below to get more info about:

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