Pharmacovigilance

Date of Adverse Drug Reaction (ADR) - DD/MM/YYYY

Reporter - Organisation

Reporter - First Name

Reporter - Last Name

Reporter - Contact Number

Reporter - Email Address

Reporter - Country

Reporter - City

Reporter - Address

Patient - First Name

Patient - Last Name

Patient - Gender Patient - GenderFemaleMale

Patient - Weight in kilogram (kg)

Patient - Height in centimeter (cm)

Patient - Date of Birth - DD/MM/YYYY

Patient - Country

Description of Event (according to the reaction side and the date the reaction started and ended)