Suspect adverse reaction report form

    Step 1: Details of the reporting person

    Step 2: Patient data


    Step 3: Side effects

    threat to lifepermanent or substantial disability or incapacityhospitalisation or prolongation of hospitalisationother which the doctor to the best of his knowledge considers to be seriousdeath
    outpatienthospital recovery without permanent consequencesrecovery with permanent consequencesis undergoing treatment for symptomsunknown

    Step 4: The drug used

    Drug YesNo

    Step 5: Additional information