Reporter Information
Name/Initials
*
Age or Date of Birth
*
or
Gender
*
--Select--
Male
Female
Other
Contact No.
*
+91
Email ID
Reporting for/by
*
Self
Physician/Prescriber
Others
Country of Incidence
--Select--
India
Afghanistan
Albania
Algeria
Andorra
Angola
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahrain
Bangladesh
Belarus
Belgium
Bhutan
Bolivia
Brazil
Canada
Chile
China
Colombia
Croatia
Cuba
Czech Republic
Denmark
Egypt
Ethiopia
Finland
France
Germany
Ghana
Greece
Hungary
Iceland
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Japan
Jordan
Kazakhstan
Kenya
Kuwait
Malaysia
Mexico
Morocco
Myanmar
Nepal
Netherlands
New Zealand
Nigeria
Norway
Oman
Pakistan
Philippines
Poland
Portugal
Qatar
Romania
Russia
Saudi Arabia
Singapore
South Africa
Spain
Sri Lanka
Sweden
Switzerland
Taiwan
Thailand
Turkey
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Venezuela
Viet Nam
Yemen
Zambia
Zimbabwe
Suspected Adverse Reaction
Event Term (Eg: Headache, Vomiting, etc)
*
Event Reaction Start Date
Event Reaction Stop Date
Onset Duration Time
Seriousness of the reaction
Yes
No
Seriousness Type
--Select--
Resulted in Death
Was Life Threatening
Resulted in Disability
Resulted in Birth Defects
Resulted in Hospitalisation
Medically Significant
Describe Event/Reaction with treatment details, if any
Outcomes
--Select--
Complete Recovery
Condition Deteriorated
Condition Improving
Condition Unchanged
Fatal or Death
Recovered with Sequelae
Unknown
Additional Supporting Documents
Action Taken
Name (Brand/Generic)
Event Relatedness to drug
-- Please Select --
Certain
Probable
Possible
Unlikely
Unclassifiable
Unassessable
Did Reaction abate after stopping drug?
-- Please Select --
Yes
No
Unknown
N/A
Did Reaction reappear after Reintroduction?
-- Please Select --
Yes
No
Unknown
N/A
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Concomitant Medication(s)
Name (Brand/Generic)
Dose used
Route used
Daily Dose(s)
Therapy Start Date
Therapy End Date
Indication
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Relevant Medical History/Lab Tests
Additional Supporting Documents