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Our family
History of Establishment
Actoverco and Covid
Goals and Strategies
Honors and Certificates
Export Holding in the Field of Export
Our family
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Our family
Pharmaceutical Group Introduction
Food Industry Group Introduction
Production and Research Sites Introduction
Our business partners
Social Responsibility
Products
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Products
All products
Infectious Diseases
Respiratory Drugs
Gastrointestinal Drugs
Kidney and urinary tract medications
MS Drugs
Neurological Drugs
Psychiatric medication
Skin and Hair Medicines
Gynecological Drugs
Cardiovascular Drugs
Transplant and Cancer Drugs
Diabetes
Pain Relievers
Merck Products
Other Drugs
Multimedia
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Multimedia
Pictures Gallery
Video Gallery
Exhibition Presences
Company introduction catalog
Updates
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Updates
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Statements
Events
Health Topics
Inovation
Drug Adverse Reaction Report Form
Actoverco Pharmaceutical Company
Reporter profile
First and last name
*
Contact phone
*
History
YYYY slash MM slash DD
Reporter
*
Treatment staff
Patient
Patient companion
Job
*
Doctor
Nurse
Pharmacist
Other
Other
Address
1. Patient profile
First and last name
*
Age
Weight (kg):
Telephone
Gender
*
Male
Female
Other
Pregnant
Yes
No
Lactating
Yes
No
Address
2. Type of drug side effect observed and therapeutic measures taken
Rate
*
3. Date of onset of drug reaction
History
YYYY slash MM slash DD
Rate
4. How long has the condition lasted?
Rate
5. Patient history: (allergies, hereditary diseases, enzyme deficiencies, current diseases, addictions, etc.)
Rate
6. History of any past drug side effects for the patient
Rate
7. Has the observed side effect decreased after stopping the medication?
Answer
Yes
No
I don't know, the medication hasn't been
I don't know, the medication hasn't been re-prescribed.
8. Has the condition reappeared after repeated use of the medication?
Answer
Yes
No
I don't know, the medication hasn't been discontinued.
I don't know, the medication hasn't been re-prescribed.
9. Finally, a drug side effect
Answer
Recovery
Lack of improvement
organ deficiency
Death
Other
Other
10. Has a medication complication led to the patient being hospitalized?
Answer
Yes
No
11. Paraclinical drug findings related to the observed complication
Rate
The results of relevant paraclinical tests (including: blood test results, types of CT scans, MRI, endoscopy, etc.) should be mentioned if available.
12. Drugs suspected of causing side effects
Note: The meaning of pharmaceutical strength is the amount of active ingredient in the dosage form used. (For example: 50 mg ampoule, 100 mg tablet, etc.)
3
Drug name
Pharmaceutical form and strength
Daily dosage
Way of consumption
Usage
Start date of use
Expiration date
Manufacturing serial number
Manufacturer
13. Other medications the patient was taking at the time of the complication
Note: The meaning of pharmaceutical strength is the amount of active ingredient in the dosage form used. (For example: 50 mg ampoule, 100 mg tablet, etc.)
3
Drug name
Pharmaceutical form and strength
Daily dosage
Way of consumption
Usage
Start date of use
Expiration date
Manufacturing serial number
Manufacturer
Other related explanations
Rate
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