Patient Gender MF *if pregnant, gestational age Adverse event(s) Clinical and paraclinical description of the adverse event Appearance date: *if not, time to onset after taking: Adopted conduct: withdrawal of medecine Dose reduction Hospitalization Prolongation of hospitalization Event evolution : Favorable Sequel Subject not yet recovered Death Unknown Medications and other health products taken by the patient (in descending order of suspicion) Specialty nameand presentation dosage and routeof administration Lot number Starting date Stoping date Indication Terms of Dispensation and Taking(*) (*) Specify if, Medical Prescription: 1 Self-medication:2 Medication error:3 Defective product:4 If Vaccine: Number of takes: Place of vaccination: Public sector Private Vaccination campaign If medicinal plant: Quantity: Part used: Taken in: Infusion Decoction Maceration Medication or re-administered health product: YesNo Which one: Reappearance of the adverse event: YesNo Describe Observation made by: Doctor Dentist Pharmacist Nurse Practice place: CHUPublicPrivate
