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اليقظة الدوائية | aljazeera pharma
Home / اليقظة الدوائية

اليقظة الدوائية

    نموذج الإبلاغ عن الآثار الجانبية / Pharmacovigilance Reporting Form

    1) معلومات المُبلِّغ / Reporter Information (Optional)


    2) معلومات المريض / Patient Information

    الجنس / Gender


    3) تفاصيل المستحضر المشتبه به / Suspected Drug(s) Information

    طريقة اعطاء الدواء / Route of Administration


    4) تفاصيل الأثر الجانبي / Adverse Event Details

    هل لايزال مستمراً؟ / Is it ongoing?

    تحسَّنت الأعراض بعد إيقاف الدواء؟ / Improved after stopping medicine?

    هل عاد العرض عند اعادة الاستخدام؟ / Reoccurred on re-challenge?

    هل استدعى دخول المستشفى؟ / Required hospitalization?

    نتيجة الحالة / Outcome of the event


    5) أدوية أخرى / Concomitant Medications

    6) التاريخ المرضي / Medical History

    حمل أو رضاعة / Pregnancy or Lactation


    7) مرفقات / Attachments

    يرجى إرسال النموذج إلى / Please send this form to:


    📧
    pv@aljazeerapharma.com



    07761777611