SIDE EFFECTS REPORTING FORM

Age

Gender
MaleFemale

Height (cm)

Weight (kg)

Full name

Phone

Address

Email

You are
ConsumerDoctorPharmacistOther healthcare professional

Date of death

Recovery
YesNoUnknown

Side effect start date

Side effect end date

Product name

Concentration

Batch number

Treatment start date

Treatment end date

Dosage

Frequency

Route of administration

Was the product stopped after the side effect?
YesNo

Did the effect stop?
YesNoNot applicable

Was the product restarted?
YesNoNot applicable

Did the effect reoccur?
YesNoNot applicable