RIM PHARMA

Spécialisé dans la production et la commercialisation de spécialités radiopharmaceutiques dédiées à la Médecine Nucléaire

Home Pharmacovigilance form

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:




Event evolution :




Medications and other health products taken by the patient (in descending order of suspicion)

Specialty name
and presentation





dosage and route
of 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:


If medicinal plant: Quantity:
Part used:
Taken in:



Medication or re-administered health product:
YesNo
Which one:
Reappearance of the adverse event:
YesNo
Describe

Observation made by:






Practice place: