Pharmacovigilance

Adverse Event Reporting Form

patient details

Patient Initials*

Gender
MaleFemaleOthers

Age*

Date of Birth*

Health Information

Reason(s) for Taking Medicine(s)*

Medicines Advised by*

Details of Person Reporting the adverse effect

Name of Reporter*

Email ID*

Contact Number*

Address Line 1*

Address Line 2

City*

State*

Country*

Details of Medicine Taking/Taken

Medicine Name*

Dosage form*

Dose of
Medicine*

Batch No.*

Expiry Date*

Start Date*

Stop Date*

Describe the adverse effect

Description

Reaction Detail

What did the adverse effect start:*

What did the adverse effect stop:*

Adverse effect is still continuing:
YesNo

Concomitant drug and dates of administration

Description

*This reporting is voluntary, has no legal implication and aims to improve patient’s safety. Your active participation is valuable. This information provided in this form will be forwarded to our PV department for follow up. You are requested to cooperate with the PV officials when they contact you for more details. Please do report even if you don’t have all the information.

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Adverse Event Reporting Form

Nature of Event

patient details

Health Information

Details of Person Reporting the adverse effect

Details of Medicine Taking/Taken

Describe the adverse effect

Reaction Detail

How bad was the adverse effect*

Concomitant drug and dates of administration

Phone

Address

Email

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