Adverse Event Reporting
Pharmacovigilance & Patient Safety System
HEALTH CARE PROFESSIONAL FORM
Reporting Region
Select Country
Zimbabwe
South Africa
Botswana
Namibia
1. Patient Information
Initials
Enter patient's initials
Age
Enter age in years
Sex
Select
Male
Female
Other
Select patient's gender
Medical History
List relevant past medical conditions
2. Adverse Event
Description
Investigations
Start Date
Stop Date
Action Taken
Outcome
3. Suspected Drug
4. Concomitant Medication
Medicine
Dose
Route
Start
Stop
X
+ Add Medication
Add all medications the patient is taking alongside the suspected drug
5. Risk Factors
6. Reporter Details
Submit Report