• Cambodia
  • India
  • Kazakhstan
  • Kenya
  • Malaysia
  • Moldova
  • Myanmar
  • Philippines
  • Tajikistan
  • Ukraine
  • Uzbekistan
  • Vietnam

Report ADR

Report ADR

Report ADR

    ALL PROVIDED INFORMATION IS CONFIDENTIAL AND NON-DISCLOSURE
    WITH THE EXCEPTION OF THE CASES STIPULATED BY LAW
    कानून द्वारा निर्धारित मामलों को छोड़कर सभी प्रदान की गई जानकारी गोपनीय और गैर-प्रकटीकरण है



    MaleFemale

    YesNoUnknown

    YesNoUnknown

    Yes



    YesNo


    SUSPECTED DRUG(S)









    OTHER DRUGS (Taken within the last 3 months)









    SUSPECTED ADVERSE DRUG REACTION(S) (ADR)




    YesNoUnknown

    YesNoUnknown

    ACTION TAKEN TO TREAT THE ADR

    NoneDrug withdrawalDose reducingCo-treatment cessationMedicinal therapyNon-medicinal therapy (including surgical intervention)Other (indicate):

    YesNo

    OUTCOME

    Recovering without consequencesImprovement of stateState without changesDeath related to the ADRDeath not related to the ADRRecovering with the consequences (indicate):Unknown

    CRITERIA OF SERIOUSNESS


    Hospitalization – Initial or prolongedLife threateningDisabilityProlongation of outpatient therapyCongenital malformationClinically significant condition (indicate):

    INFORMATION ABOUT THE REPORTER (Person who informed about the ADR)

    DoctorMedical RepresentativeProfessional belongingPharmaceuticalClinically significant condition (indicate):