Gender:
Male Female 

Date of Birth:

Age:

Height:

Weight:

Suspected Drug Info

Name of Drug:

Batch No:

Expiry Date:

Manufacturer/Marketer (In case of imported products):

Dosage:
 Tablet Capsule Syrup Injection Sachet Others

Name of disease for which drug was used /Indications /Diagnosis:

Route:
 Oral IM Inj IV Inj

First date of treatment:

Last date of treatment:

Concomitant Medication:

Doses Taken / Prescribed

Clinical Investigation:

Adverse Drug Reaction

Date of Onset:

Date Reaction stop:

Diagonsis:

Event Discription:

Management of Event:

Seriousness Of Reaction:

Outcome of Reaction

Outcome of Reaction:
 Yes No

Date Of Death:

Cause Of Death:

Incase Of Exposure During Pregnancy

Last date of Period:

Expected Delivery Date:

Reporter Information

Name:

Profession/Qualification:

Hospital/Clinic:

Please fill in the fields as accurate as possible. If there are fields you cannot fill in, please write "unknown". Fields marked with * must be filled in.

if you have further relevant information, please use the field 'Additional information'

Are you the patient

 Yes - I am the patient No - I am reporting on behalf of someone else

Phone No:

Designation:

Date Comlpeted

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Head of Medical Affairs (Pharmacovigilance)
CCL Pharmaceuticals (Pvt) Ltd
65 - Industrial Estate,
Kot Lakhpat
Lahore-54660, Pakistan
mail.pv@cclpharma.com