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Al Naghi Company
ADVERSE EVENT REPORT FORM
Control No.
Date & Time
02/12/2023 04:25 AM
PATIENT INFORMATION
Patient Name
Date of Birth
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Gender
Male
Female
Pregnant
Yes
No
N/A
Height
Delivery Date
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Weight
REPORTER INFORMATION
Name
Contact No.
Address
E-mail
Qualifications
Physician
Pharmacist
Other Health Professional
Non-Heath Professional
SUSPECTED DRUG(S)
Product Name
Lot/Batch No.
Expiry Date
Formulation
Dosage
Start Date
End Date
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ADVERSE EVENT DESCRIPTION
Description
Start Date
End Date
Outcome
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Death
Life-Threatening
Hospitalization
Disability
Congenital Anomaly
Others
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ACTION TAKEN
Increase Dosage
Decrease Dosage
Dose no changed
Withdrawn
N/A
Did Adverse Event (AE) stopped after stopping suspected drug?
Yes
No
N/A
Did Adverse Event (AE) reappear after restarting suspected drug?
Yes
No
N/A
FURTHER INFORMATION
FRM/07-025
* Information obtained in this form/website is made through the user's concent, strictly confidential and is only for the exclusive use of Al Naghi Company and it's respective registration holder. Under no circumstance that this form be reproduced, reprinted, distributed and/or communicated in any form other than it's intended purpose.
* I hereby give my consent to be contacted by Al Naghi Company or its respective registration holder
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