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ADVERSE EVENT REPORTING FORM
Home
adverse event reporting form
* Marked data is compulsory
Patient Information
Suspected Adverse Event
Suspect medication(s)
Medication History
Reporter Details
Full Name *
Weight in kg
- Select Gender * -
Male
Female
Other
- Select Country of Event Occurence * -
Abkhazia
Afghanistan
Åland Islands (Finland)
Albania
Algeria
American Samoa (US)
and Tristan da Cunha (UK)
Andorra
Angola
Anguilla (UK)
Antigua and Barbuda
Argentina
Armenia
Artsakh
Aruba (Netherlands)
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda (UK)
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
British Virgin Islands (UK)
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands (UK)
Central African Republic
Chad
Chile
China
Christmas Island (Australia)
Cocos (Keeling) Islands (Australia)
Colombia
Comoros
Congo
Cook Islands (NZ)
Costa Rica
Croatia
Cuba
Curaçao (Netherlands)
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
DR Congo
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
F.S. Micronesia
Falkland Islands (UK)
Faroe Islands (Denmark)
Fiji
Finland
France
French Polynesia (France)
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar (UK)
Greece
Greenland (Denmark)
Grenada
Guam (US)
Guatemala
Guernsey (UK)
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong (China)
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man (UK)
Israel
Italy
Ivory Coast
Jamaica
Japan
Jersey (UK)
Jordan
Kazakhstan
Kenya
Kiribati
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau (China)
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Moldova
Monaco
Mongolia
Montenegro
Montserrat (UK)
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia (France)
New Zealand
Nicaragua
Niger
Nigeria
Niue (NZ)
Norfolk Island (Australia)
North Korea
North Macedonia
Northern Cyprus
Northern Mariana Islands (US)
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands (UK)
Poland
Portugal
Puerto Rico (US)
Qatar
Romania
Russia
Rwanda
Saint Barthélemy (France)
Saint Helena, Ascension
Saint Kitts and Nevis
Saint Lucia
Saint Martin (France)
Saint Pierre and Miquelon (France)
Saint Vincent and the Grenadines
Samoa
San Marino
São Tomé and Príncipe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten (Netherlands)
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Korea
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Sweden
Switzerland
Syria
Taiwan (China)
Tajikistan
Tanzania
Thailand
Togo
Tokelau (NZ)
Tonga
Transnistria
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands (UK)
Tuvalu
U.S. Virgin Islands (US)
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Wallis and Futuna (France)
Western Sahara
Yemen
Zambia
Zimbabwe
Email address
Contact number
Date of Birth
Next
Event term
Date of Event Start *
Date of Event End
- Select Outcome * -
Recovered
Recovering
Not yet recovered
Fatal
Recovered with Sequelae
Unknown
- Select Severity Level * -
Mild
Moderate
Severe
Outcomes attributed to adverse event (check all that apply)
Death
Disability
Life-threatening
Congenital anomaly
Other (Medically Significant)
Hospitalization - initial or prolonged
Description of the event/problem
Casualty:
Drug
Concomitant medication
Co-existing disease
Other
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Details of our product(s)
Start Date of Product *
End Date of Product
- Select Brand Name * -
Abitate
Abitate U
Adlumab
Aldactone
Aldactone T
Alfalog
Alpha Ketoanalogue
Alumina-plus-Magnesia-plus-Simethicone OS
Alumina-plus-Magnesia-plus-Simethicone Tab
Alumina-plus-Magnesia-plus-Simethicone-plus-Oxethazaine
Amlodipine
Anarzole
Arpimune ME
Arpimune-O
Avastimab
Azaplast
Azathioprine
Azathioprine Tablet
Azopen
Azoran
Bortemap
Bulalfa
Carbozar
Chemofit
Cilren
Clopidogrel
Clotrimazole
Crann-D
Cyclosporine OS
Cyclosporine SGC
Darba
Daslin CD
Daslin NF
Diphenoxylate Hydrochloride
Docel
Draminate
Duo-Cytra
Emcitaben
Erubin
Fixpritant
Fospritant
Frastim
Gliclazide
Gliptinext
Gliptinext-M
Haloperidol
Haloperidol Decanoate
Hermab
Imunotac
Infura
Ishine XT
Lamotrigine
Lomo RS
Lomofen-plus
Lomotil
Losartan Potassium
Losartan Potassium-plus-Hydrochlorothiazide
Meejoy MF
Metformin
Minmin D3
Minmin pb
Minmin Tonic
Mofetyl
Mofetyl-S
Mycophenolate Mofetil
Mycophenolate Mofetyl
Mycophenolate Sodium
Nabpac
Naprosyn
Naprosyn D
Naprosyn ES
Naprosyn SR
Naprosyn suspension
Naprosyn-plus
Naprosyn-plus-gel
Neomustin
Neosez
Neoxal
Nerv M
Nicorandil
Nicorandil Tab
Norpace New
NuGliptin
NuGliptin M
Nutrikit
Pantoprazole Sodium Sesquihydrate
Peg Frastim
Pemexar
PPBcc
Propantheline Bromide
Quinfamide
Rabee 20
Rabee D
Rabee L
Religel
Rinostat-plus
Risperidone
Risperidone Tab
Rivorca
Romilast
Romilast B
Romilast BL
Romilast FX
Romilast L
RP-CARN
RPO
RPTEL
Serenace
Sertraline
Sertraline Tab
Sildura
Silosmart
Spironolactone
T-Jaki
Tacrolimus Capsules
Tadgo 10-20 mg
Tadgo 5 mg
Tamflo
Tamflo D
Tamflo DFZ
Temotide
Timinib
Tolvaptan
Tricaine Alma
Tricaine AR
Tricaine MPS
Tricaine S
X-Mab
Xecap
Z pac
Zestmab
Zubidox
- Select Route -
Oral
Parentral
Topical
Buccal
Nasal
Ophthalmic
Rectal
Intra Vaginal
- Select Frequency -
Daily Once
Daily Twice
Daily Thrice
Labeled Strength
Manufacturer
Lot No
Dose
Event abated after use
- Select Option -
Yes
No
NA
Expiry Date
Diagnosis for use *
Event reappeared after reintroduction
- Select Option -
Yes
No
NA
Add More Product
Click to add Concomitant Medication details
Start Date of Product *
End Date of Product
Brand Name *
Dose
- Select Route -
Oral
Parentral
Topical
Buccal
Nasal
Ophthalmic
Rectal
Intra Vaginal
- Select Frequency -
Daily Once
Daily Twice
Daily Thrice
Indications
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Relevant tests/laboratory data
Other Relevant History
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Reporter *
- Select Option -
Consumer
Physician
Medical Representative
Name *
Address
Contact Number
Email ID *
Submit
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