Pharmacovigilance

Notifier

Full name*

Title

Health Institution*

Country*

Email*

Patient

Initials*

Age*

Height (m)*

Weight (kg)*

Gender*

Male Female

Medicinal Product Suspected

Drug*

Medicinal product name*

Batch number

Storage condition

Medical History and Pathologies

Tobacco

Alcohol

Obesity

Diabetes

Allergies

Other

Oncological Diagnosis*

Protocol*

Cure Number*

Date of First Cure

Drugs

Drug 1

Premedication

Postmedication

Side Effect*

Seriousness and detailed description of the suspected side effect: (photos, biology…)

Severity*

Evolution*