ABOUT THIS MEDICINE

How is this medicine related to the side effect?

SuspectedConcomitant MedicationUsed for treatment of the side effect

WHEN AND WHY THIS MEDICINE WAS TAKEN:

When did the person experiencing the side effect start taking the medicine?

Start Date:
End Date:

WHY DID THEY TAKE THIS MEDICINE?

HOW THE MEDICINE WAS TAKEN?

Select formulationCreamCapsuleDropSolutionPatchTabletunknownOther

Please selectCutaneous- on the skinInhalationIntramuscularIntrathecalIntravenousNasalOphthalmicOralParentheralRectalSubcutaneousSublingualTransdermalTransplacentalUnknownVaginalOther

Select dose unitmg (milligram)ug (microgram)mg/kg (milligram/kilogram)Gtt (Drop)DF (Dosage Form)kg (kilogram)g (gram)ml (mililitre)% (percent)ug/kg (microgram/kilogram)ul (microlitre)mbq (mecabequeral)mol (mole)mmol (milimole)umol (micromole)IU (international Unit)

Please selectOnce dailyTwice a dayThree Times a dayFour times a dayEvery eveningEvery 12 hoursEvery 48 hoursEvery 72 hoursEvery other dayOnce a weekOnce every two weeksOnce a monthOne single doseAs neededOther

ADDITIONAL INFORMATION

Lot or batch No.

2. SIDE EFFECT

ABOUT THE SIDE EFFECT

Select the outcomeComplete recoveryClinical deteriorationClinical improvementNo modification observedFatalRecovered with sequelaeUnknown

Start Date:
End Date:

DESCRIBE THE SIDE EFFECT IN MORE DETAIL AND IF ANY TREATMENT WAS NEEDED:

SERIOUSNESS

UnknownNo, it was not seriousYes, it was serious

3. PATIENT

ABOUT THE PERSON EXPERIENCING THE SIDE EFFECT

MaleFemaleUnknown

DETAILS ABOUT THE PERSON

AgesMonthsDays

CmFeetInches

KilogramsPounds

4. CONTACT DETAILS

REPORTER AND CONTACT INFORMATION

CONFIRMATION OF THIS REPORT

CONTACT INFORMATION

Select reporter typeHealth Care ProfessionalPatient/ConsumerOther Non-Health Care ProfessionalHealth Authority

Yes, contact my health care professional for more information about this reportNo, you cannot contact my health care professional

Yes, you can contact meNo, you cannot contact me