Adverse Drug Report Form Actoverco Pharmaceutical Company Reporter ProfileName*Phone Number*DateReporter* Treatment Staff Patient Accompany the patient Job* Doctor Nurse Pharmacist Other Other:Address1. Patient ProfileName*AgeWeight (kg)PhoneGender* Male Female Other Pregnant Yes No Breastfeeding Yes No Address2. The type of drug complication observed and treatment measures performedDescription*3. Date of onset of drug side effectsDescription4. How long has the complication lasted?Description5. Patient history: (Allergy, hereditary disease, enzyme deficiency, current diseases, addiction, etc.Description6. History of any past drug side effects for the patientDescription7. Has the observed complication decreased after stopping the drug?Response Yes No I do not know, the medicine has not been stopped I do not know, the drug has not been prescribed again 8. Has the complication reappeared after repeated use of the drug?Response Yes No I do not know, the medicine has not been stopped I do not know, the drug has not been prescribed again 9. Finally a drug complicationResponse Recovery Lack of recovery Maim Death Other Other:10. Has the drug complication led to the hospitalization of the patient?Response Yes No 11. Paraclinical drug findings related to the observed complicationDescriptionRelevant paraclinical test results (including: blood test results, CT scan, MRI, endoscopy, etc.) should be noted if available. 12. Medications suspected of having a complicationNote: Drug power refers to the amount of active ingredient in a drug. (For example: 50 mg ampoules, 100 mg tablets, etc.) 1*Medicine NameShape of MedicineDaily IntakeWays to consume 2ConsumableDate of UseExpiry DateSerial NumberFactory 13. Other drugs used by the patient at the time of complicationNote: Drug power refers to the amount of active ingredient in a drug. (For example: 50 mg ampoules, 100 mg tablets, etc.)3Medicine NameShape of MedicineDaily IntakeWays to consume 4ConsumableDate of UseExpiry DateSerial NumberFactory File Drop files here or Select files Max. file size: 5 MB, Max. files: 3. Other Related DescriptionsDescriptionSecurity Code
