Patient Information

Initials

Gender ^* Please SelectMaleFemale

Age

Country

Suspected Drug Details

Drug Name/s^{* (if it is more than one drug please use comma)}

Name of Disease for Which Drug was Used^(Indication)

Batch / Lot Number

Dose and Frequency

Manufacturer/MarketerPlease SelectSAMI ProductHealthtek ProductAny Other

Any Other

DosagePlease SelectTabletsCapsuleSuspensionSyrupInjectionSachetTopicalOthers

Other

Start Date

Stop Date

Adverse Event (AE) Details

Date of Onset

Resolved / Improved Date

Adverse Event Details ^{* (provide diagnosis if known)}

Management of Events

Seriousness
Please SelectDeathLife threatening (Immediate Risk of Death due to an Event)Initial / Prolonged HospitalizationBirth DefectsPersistent / Significant DisabilityMedically Significant (important medical events that may jeopardize the patient and may require medical / surgical intervention to prevent the other outcome)Non Serious

Outcome
Please SelectDeathNot ResolvedResolvedResolved with SequelaeResolvingUnknown

Pregnancy Exposure

Last Date of Menstrual Cycle

Expected Delivery Date

Name

Profession / Qualification

Telephone Number ^*

Email Address

Additional Information ^{*(provide information about your medical history, other medications or any laboratory finding/s you would think would help)}

Permission to Contact HCP

If “Yes”, please provide your doctor’s contact details Yes No

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