Reaction and Treatment
- Patient Information
Please enter some information about the person who had the adverse reaction.
Initials of Patient
Enter patient's initials here OR their ID number and type below.
Enter patient's ID number OR enter their initials above..
If you entered a patient ID number, specify the ID type here.
Patient Date of Birth
Enter the patient's date of birth here OR enter their age below.
Enter the patient's age here OR enter their date of birth above.
Age Unit of Measure
Enter weeks, months, or years for the patient's age here.
Patient's weight (kg)
Ethnic Group of Patient
- Product Information
Please enter information about the product you suspect caused the reaction and about other products taken.
Drug Strength Unit
Add Product Information item
- Test Results
Enter information about any tests done for the reaction, along with the results.
Low Test Range
High Test Range
Add Test Results item
- Reaction and Treatment
Enter information about what happened and how it was treated.
Description of reaction
Start date of reaction
Enter the start date of the reaction OR enter the estimated start date in the next field.
Estimated start date of reaction
If you don't know the exact start date of the reaction, enter the estimated start date here.
Did any of these reactions happen?
Resulted in death
Requires inpatient hospitalization or prolongation of existing hospitalization
Results in persistent or significant disability/incapacity (as per reporter's opinion)
Is a congenital anomaly/birth defect
Other medically important condition
Was treatment given for the reaction?
What treatment was given for the reaction?
What was the outcome of the reaction?
Not recovered/not resolved
Recovered/resolved with permanent complications
What was the date of recovery from the reaction?
Enter date if patient died from the reaction
Other relevant information
For example, does the patient have other medical problems?
- Reporter Information
Enter information about the person reporting the reaction.
Name or initials of person reporting information
Telephone Number for reporter
Reporter E-mail Address
Profession of reporter
Consumer or other non-health professional
Other Health Professional
Report reference number (if any)
Reporter place of practise
Keep reporter confidential?
Do you want your identity kept confidential except to be contacted by the national medical regulatory authority or the World Health Organization if they need additional information?
Please preview your data entered and then click the finish button when ready...
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