PHARMACOVIGILANCE – DAR ESSAYDALI

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REPORT A CASE OF PHARMACOVIGILANCE

*Name and last name

*Phone

Fax

*Email

Address

Country

*You are :

Healthcare professional

Doctor

Pharmacist

Dentist

Other healthcare professional (Specify)

General public

Patient

Other (Specify)

*Do you consent to be contacted by the pharmacovigilance department?

Yes

If you are a patient, do you agree that the pharmacovigilance department contacts the healthcare professional who monitored you?

Yes

If yes, write down here the name and contact details of the healthcare professional who managed your situation

Identification of the PATIENT

*Name (first 3 letters)

*Gender

Male

Female

Date of birth or age

*First name (first letter)

Height(m)

Weight (kg)

Medical history

SUSPECT DRUG

*Name of the drug

*Dosage

Dosage Form

Dosage

*Date of start (and time) of the treatment

Date of end (and time) of the treatment

Administration mode

Indication

Has the drug been stopped?

Yes

Unknown

Was the drug readministered?

Yes

Unknown

Does the adverse event recur after readministration?

Yes

Unknown

Other drugs

ADVERSE EVENT

*Date of occurrence

*Nature of the event

Event duration

*Describe here the event or situation subject to your declaration (exposure during pregnancy, abuse, misuse, medication error, etc.)

Severity assessment (only if you are a healthcare professional)

Serious (justify)

Not Serious

Evolution

Healing

Patient not healed yet

without sequelae

ongoing

with sequelae

Unknown

Death

due to the event

to which the event was able to contribute

unrelated to the event

Attach a file (biological test results, hospitalization reports):

doc docx mpg mpeg mp3 mp4 odt odp ods pdf ppt pptx txt xls xlsx

Case already submitted to health authorities

Yes