Pharmaghreb
Age
Gender MaleFemale
Height (cm)
Weight (kg)
Medical history and other information
Full name
Phone
Address
Email
You are ConsumerDoctorPharmacistOther healthcare professional
Other profession
Severity level DeathLife-threateningHospitalizationProlonged hospitalizationDisabilityCongenital malformationRequires medical interventionOther
Date of death
Recovery YesNoUnknown
Recovery in progress (explanation)
Side effect start date
Side effect end date
Description of the side effect
Product name
Concentration
Batch number
Treatment start date
Treatment end date
Dosage
Frequency
Route of administration
Why was the product taken/prescribed?
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
Likelihood that the product caused the side effect YesNoNot applicable
Other health products consumed
