PARTICULARS OF PATIENT
Name of Patient
*
Age
*
Weight
*
Contact No
*
Email Address
CNIC
Patient Address
*
Country
*
Gender
*
Male
Female
Other
Pregnant
*
Yes
No
Not Applicable
Relevant Medical History
Reason For Reporting
Requires or Prolongs Hospitalization
Life Threatening
Death
Permanently Disabling or Incapacitating
Congential Abnormality
Over Dose
Others
SUSPECTED DRUG
Name of Suspected Drug
*
Select
OLMIS-A
CARIPRA
EXVAL-AH
X-FIX
GNEB
SUPRACAN
PEDIET
DAXNIL
OKANZIL GUMMIES
CYT
FISHOL-D
PHYLIN
KETOR TABLETS
D4U DROPS
FERIFAM
IBNATE TABLETS
MEMOR
4ACTION
RECETAM
EXLANT
TIFL
PREPRAG
GEBON PLUS
GEBON
BANSOL
PITALO
TRAZOR
SECADRIL
VELSO
NOPCOS
CABVON
VLEP
CUBRIVA
TICS-G
PREDBON
BIMONID
SITENSA
TELMIS
SEDLOR TABLET & SYRUP
GENRIB
REZAM
OLAGEN PLUS
I-LEAF
MELADEP
D400 ORAL DROPS
D5000
GENTROP
EMGLIF-M XR
EMGLIF-M
EMGLIF
ELMAS
TIFL GUMMIES
CARTICARE PLUS
RISORA
KYROVIN
ZNBAL-D
REVIPIR
SALZINA
RITOR
RONIM
TAZBAC
CUBIL
ZOLERON
RABRO
FCM
D4U INJECTION
COMIN
WYMLY
OMARIL
NOVOM
MOVELEF
MAXLAX
LEUGEN
GENTOVIR
GENFIX
GEN-D
GABLO
FOLAT
DASVIR
AZOGEN
AUMI
ASFY
ANATIN
ACTAVIS
ZYSPAN
ZOLERIC
ZN-ONCE
ZERFIN
X-GEN INFUSION
X-GEN
VOI
VELON-M
VANCOM
TELMIS-H
TELMIS-A
TAMPRO
SOLIF
SOFOS
SOFOPAS
S-FLOX
SAXAGEN
ROSCA
RIBAX
RIBAVIL
RESPICARE
RBC-F ,RBC
RBC INJECTION
RABRO
PLOP FORTE
PIROXIM-NEO
PIRE 4+
PIRE
OSKER
OMC-D
OMC
OLVER
NT-TOX
NERAM
NEBILOL
MOVCOL
MITE
MEP-B
MEP INFUSION
LOXE
LETS
LARITH
LALAP
LAFAXINE ER
KETOR
IVAGEN
ILODON
IBNATE INJECTION
HYSPA
HAEMIC
GVIA-M
GVIA
GRAT
GENOXEN
GEN-M TABLETS AND DRY SUSPENSION
GEN-M INJECTION
GENART
EXVAL-H
EXVAL-A
EXIFIN
ERNEM
ENERVIN
EFECIP
DORLOL
DOL-P
DIPHOS
DIMIS
DEPSIT
DACLIT
CILENEM
BTNO
ACUKAT
ACLOVIR
Generic Name
*
Date of Occurence
*
Starting Date of Medication
*
Duration Of Event
*
1-2 Days
2 or More Days
Other
Duration of Event Other
*
Route of Administration
*
Discontinuation Of Drug
*
No
Yes
Dated
*
REPORTING
Particulars
Medical Practitioner
Dr
Pharmacist
Relative
Self
Nurse
Other
Other
Name
*
Phone
Email
Clinic / Hospital
Date
GUIDINES TO FILL SERIOUS ADVERSE EVENT REPORT FORM
An adverse event is "Serious", if it
• Is life threatening
• Result in permenant disability
• Result in hospitalization
• Is associated with death
• Prolongations of hospitalization
• Causes a birth defect
• Causes malignancy
• Causes a relevant organ toxicity
• Is an overdose resulting in clinically relevant signs and / or symptoms
An adverse drug event can be a manifestation of various etiologies as
• Complication of an underlying disease
• Intercurrent disease
• Coincidental accident
• Drug associated effect
• Concomitant medication
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