Pharmacovigilance

Your Report

Pharmacovigilance Report

Name *

Governorate *

Phone *

Reporter type *

Gender *

Weight (kg) *

Age *

Drug *

Concentration *

Dose *

Dosage form *

Start date *
Exact Start date

Period of use *

Reason for using the medicine *

Reporter condition now *

Action taken *

Other drug taken *

Write a short description (headache for ex) for reactions you experienced *

Did the adverse effect cause any of the following? *

Other notes *