KMCA - PharmaCovigilance

Patient details

Location

Initials

Gender

Weight

e.g.(100Kilogram , 68Pound ,2700Gram)

Height

e.g.(168Centimeter)

Date of birth

Age at time of reaction

e.g.(Year,Month,Week,Day,Hour)

Health information

Please state a short history of your disease. This is important since some reactions can only be triggered by a combination of earlier or ongoing illness, smoking habits, alcohol consumption, or allergies. You may also include any additional remarks you believe are relevant.

Reason(s) for taking medcine(s) (Disease/Symptoms)

Medicines Advised by

Adverse Reaction

Describe the reactions in your own words. For each reaction you will describe, click the (Add button) .

Describe the reaction

Starting date of reaction

End date of reaction

Duration of reaction

e.g. ( A day,one week,one month,Two Year)

Did the reaction lead to any of the following?

Describe the reaction

Starting date of reaction

End date of reaction

Duration of reaction

e.g. ( A day,one week,one month,Two Year)

Did the reaction lead to any of the following?

Drug Details

Enter the name and details for each medicine you were taking when the reaction occurred,For each Medicine you were taking, click the (Add button).

Name of the medicine

Probably causing the reaction

Quantity of medicines taken /Strength

(e.g. 100mg,Once Daily)

Dosage Form

e.g. Tablet , Capsule , ...

Expiry Date of medicines

Batch number

Date of starting medicines

Date of stopping medicines

Reason for taking the medicine

Action taken with medicine