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Pharmacovigilance
Report Side Effect
Inform the Ministry of Health
AR
EN
Report Side Effect
To contact the Pharma pharmacovigilance department
+963942011192
+905314507568
pv@e-revapharma.com
Syria - Idlib
Patient Data
Full Name
Age
Gender
Male
Female
Other
Phone Number
Weight
Height
Side Effect Data
Side Effect Name
Name of the Medicine
Preparation Number *
Date of Onset of Side Effects
Date of End of Side Effect
Symptoms
Is side effect serious?
Yes
No
If it is dangerous, select:
Threat to patient's life
Hospital admission
Prolonging patient's hospital stay
Surgical intervention to prevent injury or disability
Other:
The Action Taken:
Has use of suspected drug been discontinued?
Yes
No
Unknown
Did symptoms improve after stopping the medication or adjusting the dose?
Yes
No
Unknown
Should I resume taking the suspected medication after stopping it?
Yes
No
Unknown
Did the side effect reappear after resuming the suspected medication?
Yes
No
Unknown
Other medications and dietary supplements taken by the patient:
Name of Medicine
Medication Dose
