Patient information

    Patient Name *

    Age *

    Age Group

    Gender *

    Suspected Product Information

    Trade Name & Strength *

    Indication

    Dose

    Route

    Frequency

    Duration

    Date

    Batch No.

    Adverse Event Information

    Adverse Event

    Event Onset Date

    Event End Date

    Outcome

    Casualty

    Adverse Event

    Event Onset Date

    Event End Date

    Outcome

    Casualty

    Adverse Event

    Event Onset Date

    Event End Date

    Outcome

    Casualty


    Treatment Medication, Diagnostic & Lab Values (associated with adverse event(s))

    Action Taken: What happened after adverse reaction?

    Seriousness

    Concomitant Drugs

    Were any concomitant drugs taken?

    Reporter information

    Reporter name *

    Profession (Specialty)

    Address

    E-mail

    Phone / Mobile *

    Country *

    Date

    EMAIL

    info@deef.com

    ADRESS

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