Pharmacovigilance

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Spontaneous reporting of suspected adverse drug reactions (Mauritius)

Fill-in the form by providing all the necessary details. Note that all the fields marked with an asterisk (*) are required to be filled out.

Patient Information

4. Gender *

Reporter Details

SUSPECTED MEDICATION(S) Please add other suspected medications on a separate sheet if needed

ADVERSE REACTION / EVENT Please use the verso sheet if needed

25. Date and Time of onset of reaction

28. Action Taken
29. Seriousness
If serious, please select reason for seriousness *
30. Evolution

33. PATIENT HISTORY – Details of patient current and past medications history

Has the patient taken the suspected drug before?
Click or drag a file to this area to upload.

34. SUSPECTED MEDICATION (To be completed by Pharmacy Section)

For Office Use Only

Please return this form to the National Pharmacovigilance unit Room 1022, Tel: 201 1896. Email: [email protected]