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
LOVEAWAKE.RU
REVIPIR
SALZINA
RITOR
RONIM
TAZBAC
CUBIL
ZOLERON
RABRO
FCM
D4U
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
X-GEN
VOI
VELSO
VELON-M
VANCOM
TELMIS-H
TELMIS-A
TAMPRO
SOLIF
SOFOS
SOFOPAS
S-FLOX
SAXAGEN
ROSCA
RIBAX
RIBAVIL
RESPICARE
RBC-F ,RBC
RBC
RABRO
PLOP FORTE
PITALO
PIROXIM-NEO
PIRE 4+
PIRE
OSKER
OMC-D
OMC
OLVER
NT-TOX
NERAM
NEBILOL
MOVCOL
MITE
MEP-B
MEP
LOXE
LETS
LARITH
LALAP
LAFAXINE ER
KETOR
IVAGEN
ILODON
IBNATE
HYLU
HAEMIC
GVIA-M
GVIA
GRAT
GENOXEN
GEN-M
GEN-M
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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