DECLARATION OF ADVERSE EFFECT POSSIBLY DUE TO A MEDICATIONConcerned patientName (first 3 letters) *0 / 3First name (first letter) *0 / 1GenderMFWeightKg0 / 3Heightm0 / 4Date of birthDaySelect day12345678910111213141516171819202122232425262728293031MonthSelect month123456789101112YearSelect Year212521242123212221212120211921182117211621152114211321122111211021092108210721062105210421032102210121002099209820972096209520942093209220912090208920882087208620852084208320822081208020792078207720762075207420732072207120702069206820672066206520642063206220612060205920582057205620552054205320522051205020492048204720462045204420432042204120402039203820372036203520342033203220312030202920282027202620252024202320222021202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925Patient's medical history / Factors that may have contributed to the occurrence of the adverse effect:TobaccoYESNOAlcoholYESNOAllergyYESNOSpecify the allergyOtherNotifierName *First name *Phone *Email addressQualification *promotion teamdoctorother health professionalpatientparent of patientConcerned medicine(s)medicine *Route of administrationDosageBatch numberStart of useEnd of useWhy was the product taken?Pharmacy that dispensed the productDid you take any other medicines during your treatment with the above medicine?YesNoPlease fill in the following fields:Medicine *Route of administrationDosageWhy was the product taken?Start of useEnd of useAdverse eventDetailed description of the observed adverse effect: *Date of occurrenceDaySelect day12345678910111213141516171819202122232425262728293031DaySelect month123456789101112YearSelect Year212521242123212221212120211921182117211621152114211321122111211021092108210721062105210421032102210121002099209820972096209520942093209220912090208920882087208620852084208320822081208020792078207720762075207420732072207120702069206820672066206520642063206220612060205920582057205620552054205320522051205020492048204720462045204420432042204120402039203820372036203520342033203220312030202920282027202620252024202320222021202020192018201720162015201420132012201120102009200820072006200520042003200220012000199919981997199619951994199319921991199019891988198719861985198419831982198119801979197819771976197519741973197219711970196919681967196619651964196319621961196019591958195719561955195419531952195119501949194819471946194519441943194219411940193919381937193619351934193319321931193019291928192719261925Duration of the effectConditions of occurrenceNormal conditions of useMedication errorOverdoseMisuseAbuseAdverse effect related to occupational exposureOther:SeverityHospitalization or prolonged hospitalizationPermanent disability or incapacityLife-threatening conditionDeathCongenital anomaly or malformationOther serious medical conditionNot seriousProgressionRecoverySubject not yet recoveredDeathUnknownWithout sequelaeWith sequelaeOngoingDue to the effectTo which the effect may have contributedUnrelated to the effectActions taken in response to the adverse effect:Discontinuation of the medicationDosage reductionTreatment of the symptoms that accompanied the observed adverse effectOther :In case of reintroduction of the suspected medicine, was there a reappearance of the adverse effect?YesNoDoes the report concern a newborn?YesNoThe medicines were received:By the fatherBy the newbornBy the mother during pregnancyDirectlyThrough breastfeedingduring the quarter number?Adverse effect in the fetus or newbornCongenital anomalyDevelopmental delay in the fetus or newbornFetal death or miscarriageOtherAttach a copy of the available medical documents (laboratory test results, hospitalization reports, etc …) Hide the patient's identityChoose FileNo file chosenDelete uploaded fileCONFIDENTIALITYAll data declared on this form, including data concerning the identity of the persons concerned, are treated confidentially in accordance with the provisions of Tunisian regulations.The personal data that you have provided are processed by the Pharmacovigilance department of Pharmacare laboratories for the purpose of pharmacovigilance as notified to the INPDP (National Authority for the Protection of Personal Data).By checking this box, I certify that I have read the information relating to the confidentiality of personal data.Send the message
