Nature Of Event ( Check All That Apply) Adverse Event/ Side EffectPregnancy/LactationOverdoseLack Of EfficiencyMisuseAbuseProduct ComplaintMedication Error
Patient Name Gender MaleFemaleOther
Age
Description of Adverse Event / Side Effect/ Any other experience such as lack of effect, Medication error
What happened to the event later?/ Outcome Complete RecoveryOngoingRecoveringUnknownDiedOther
Relevent Medical History( If Available)
Full Name
Country
Phone
Address
Email
Are You Also the Patient? YesNo
Relationship With Patient
