Name of patient (required)
Your Email (required)
Relevant Medical History
Name of Health Facility
Patient Registration Number
Reporting Doctor/Nurse /Pharmacist’s Name
Type of Event
Adverse drug reactionProduct quality problemMedication error
Reason for Reporting
Dose [strength, unit]
Route of Administration
Date of Occurrence
Duration of Event
Describe event including relevant tests and laboratory results
Action taken after the reaction
Dose stoppedDose reducedNo action taken
Was the adverse event treated?
If yes, please specify
Did reaction subside after stopping/reducing the dose of the suspected product?
Did reaction appear after reintroducing the suspected product?
Any other comments