Pharmacovigilance

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Who is reporting?

Address

Report date

Patient initials

Age (years)

Patient sex

Date of birth

Diagnosis of death

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Autopsy result

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Adverse event information

Report type

Adverse events

Event date

Approximate duration

Event outcome

Consequence

Medication information

Treatment START date

What is the role of this medication?

Treatment END date

Lot No:

Dosage

Was suspension/reduction improved?

Reintroduced & recurred??

Has this event happened before?

Have you reported this event to another institution?