Report Side Effects Of The Drug First name and Last name Age Weight GenderMenWomenPregnantPhone Residence Address Type of Drug Complication Observed and Treatment Measures Performed Date Of Onset Of Disease Complication How Long Has The Complication Lasted? History Of Any Past Drug Side Effects For The Patient Patient History: (allergies, hereditary diseases, enzyme defects, current diseases and addiction ...) Did The Observed Complication Decrease After Stopping The Drug?YesNoThe medicine has not been stoppedHas The Complication Reappeared After Repeated Use Of The Drug?YesNoThe medicine has not been used againFinally a Drug ComplicationRecoveryLack of recoveryViolation of the memberDeathOther casesHas The Drug Complication Led To The Hospitalization Of The Patient?YesNoParaclinical Findings Related To The Observed Complication Drugs Suspected Of Having a Complication (please indicate the name of the drug, the form and strength of the drug, the daily dose, the way of consumption, the use, the start date, the end date, the manufacturer and the serial number) Other Drugs Used By The Patient At The Time Of Complication (please indicate the name of the drug, form and strength of the drug, daily dose, route of use, use, start date, end date, manufacturer and serial number) Description
