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Pharmacovigilance Form

Report of Suspected Adverse Drug Reaction and Medical Related Problem

Note: Identities of Reporter, Patient and Institution will remain confidential

Patient Details
Patient’s Name/or Initial: Sex:
Weight(Kg): Height:(Cm):
Patient’s Medical Record: Pregnant
Which trimester Age
Suspected Drug(s)
Consequences of suspected reactions
Outcome On The Day of Report
Reporter Details
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