العربية
|
ENG
Global Presence
ALGERIA
BAHRAIN
EGYPT
JORDAN
KUWAIT
LEBANON
LIBYA
Oman
QATAR
SUDAN
United Arab Emirates
YEMEN
Media
Social Responsiblity
Contact Us
Home
About us
Who we are
Meet Our Board
Mission
Values
Investors
Products
Manufacturing
Quality in SPIMACO
Products Development
Plant
Partnerships
Alliances
Business Development
Pharmacovigilance
Careers
Why SPIMACO
Current Opening
Submit Resume
Adverse Event Reporting Form
Patient Information
Patient Name or Initial
*
Age
*
Age Group
Gender
*
Select
Elderly
Adult
Pediatric
Select
Male
Female
Suspeucted 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
Select
Recovered
Recovering
Not Recovered
Unknown
Fatal
Recovered w/ sequelae
Select
Related
Not Related
Not Reported
Select
Recovered
Recovering
Not Recovered
Unknown
Fatal
Recovered w/ sequelae
Select
Related
Not Related
Not Reported
Select
Recovered
Recovering
Not Recovered
Unknown
Fatal
Recovered w/ sequelae
Select
Related
Not Related
Not Reported
Treatment Medication, Diagnostic & Lab Values (associated with adverse event(s))
Action Taken: What happened after adverse reaction?
Select
Drug discontinued
Dose reduced
Dose increased
Dosage maintained
Unknown
Seriousness
Select
Unknown
Serious
Non-Serious
*
If serious indicate event seriousness criteria:
Select Criteria
Patient died
Life threatening
Permanent disability
Hospitalization
Prolonged hospitalization more than 24 hours
Congenital anomaly
Required intervention to prevent permanent impairment/damage
Required Emergency Room (ER) visit
Other
Death Date
*
Other
*
Concomitant Drugs
Were any concomitant drugs taken?
Select
No
Yes
Concomitant Drug Name
*
Indication
*
Dose/Route/Frequency
*
Start Date
*
End Date
*
Reporter information
Reporter name
*
Profession (Specialty)
Address
E-mail
Phone / Mobile
*
Fax
Country
*
Date