QATAR PHARMACEUTICAL INDUSTRIES CO

QPI-PV Report No: (for QPI use only)

Consumer/Patient Adverse Drug Reaction and Adverse Events (English)

Pharmacovigilance

1. Patient Information:
Patient Name/ Initial Sex Female Male Pregnant    Not Pregnant
Age Weight (kg) Height (cm)
2. Suspected Side Effect
Describe the reaction or problem
How bad was this side effect? (You can choose more than one)
Mild Caused serious illness
Effect daily activities Caused Death
Admitted to hospital or prolong hospitalization Cause Congenital /Birth defect
Other medically important condition
Does the side effect go away: Yes No Date:
The patient's current
condition:		 Fully recovered , Date:
Not improving 		Improving
Unknown

3. Suspected Medication:
Medication Name Batch No
Dose (for example: One 500 mg tablet twice a day):
Did you stop because of side effect? No YesDate

4. Concomitant Medications and Medical History:
Concomitant Medications (any other Medication that the patient is taking) and Medical History (any
chronic diseases that the patient has. For example: Diabetes, Hypertension, etc....)"
Concomitant Medications:Medical History:
1-1-
2-2-
3-3-
4-4-
5-5-

5. Other information
Have these symptoms has been reported to your doctor or pharmacist? Yes No Unknown
If yes, did he fill the side effects reporting form? Yes No Unknown
Can we get additional information from your treating physician? Yes No
If the answer is yes, please provide us your doctor's contact information
Doctor's name: hospital: Phone no:

6. Reporter’s Information:
Name E-mail
Address Phone Number
Source of information: Patient Pharmacist Doctor Others


Confidentiality:

Reporter's and patient's identity are held in strict confidence, information provided by the reporter will be strictly protected and will not be used in any way against him / her.