Online Adverse Event Reporting Form

Patient Information

Patient Name or Initial

Age

Age Group

Gender

Product Information

Trade Name/Generic Name & Strength

Indication

Dose

Route

Frequency

Duration

Date

Batch No.

Adverse Event Information

Adverse Event

Event Onset Date

Event End Date

Outcome

Causality

Treatment Medication, Diagnostic & Lab Values (associated with adverse event(s))

Action Taken: What happened after adverse reaction?

Seriousness

Were any concomitant drugs taken?

Reporter information

Profession (Specialty)

Treatment Medication, Diagnostic & Lab Values (associated with adverse event(s))

Address

Phone / Mobile*

Fax

City*

Date

Mohammed Mahdi Al-Shaer Corporation is run by skilled leaders who have extensive knowledge and expertise within the healthcare industry with a strong capability to successfully launch and commercialize pharmaceutical products.

QUICK LINKS

Head Office

Taiz Street, Sana'a, Yemen
(+967) 01 614401
(+967) 777077797
(+967) 01623125
alshaercorp@yemen.net.ye
www.alshaercorp.com

Online Adverse Event Reporting Form

Patient Information

Product Information

Adverse Event Information

Reporter information

Treatment Medication, Diagnostic & Lab Values (associated with adverse event(s))

1. Patient Details:

2. Describe the Side effect(s)

How bad was this side effect? (You can chose more than one)

3. Suspected Medication Information

4. Concomitant Medications (any other Medication that the patient is taking) and Medical History (any chronic diseases that the patient has )

5. Reporter’s Information:

Coil Weight