Reporting of Adverse Reactions Kindly provide as much information as possible. "*" indicates required fields Step 1 of 3 0% Reaction InformationPatient Name* Patient Name and SurnameCountry AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Identification of the country where the reaction/event occurredDate of Birth MM slash DD slash YYYY Age (Years)*SexFemaleMaleUnknownPregnantNoNot ApplicableYesPatient Height (cm) Patient Weight (kg) Adverse Drug Reaction*Please describe the symptoms in as much detail as possible.Include Relevant Test Lab DataProvide results of tests and procedures relevant to the investigation - if available. Suspect Medicine InformationSuspect Medicine(s)*Medicine identification (Product Name).Daily Dose(s)* Dosage taken i.e. One tablet every 12 hours after meals.Route(s) of Administration*OralOtherIndication(s) for Use (reasons for use)*Provide the reasons for starting treatment.Therapy Dates (Start)* MM slash DD slash YYYY Date of first administration.Therapy Dates (End) MM slash DD slash YYYY Date of last administration if medication was stopped.Therapy Duration Duration of medicine administration.Reaction Onset* MM slash DD slash YYYY Date the adverse event started.Did the Reaction Stop When the Medicine Was Stopped?YesNoNot applicableDid Reaction Reappear if the Medicine Was Readministered?YesNoNot applicableDid reaction recur on readministration? Concomitant Drug(s) and HistoryConcomitant Medicine(s) and Dates of Administration* Other Medication or treatment used by the patient Medicine Identification Date of Start of Medicine Date of Last AdministrationMedical HistoryAdditional information available e.g Co-morbidity (chronic disease), diagnostics, allergies, pregnancy with last month of period, etc. Relevant medical history and concurrent conditions (not including reaction/event)Patient Allergies Date of this Report MM slash DD slash YYYY File Upload (where required)Max. file size: 64 MB.Reporter Name* Reporter Contact Number*Reporter Email Address Send me a copy of my responses