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Pharmacovigilance

    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):