E-Pharmacovigilance Card (Apply and Download)

The information collected will be kept confidential as per our privacy policy. The objective is to create a patient’s medication history card with AE/ADR/side effect/allergic information. The card can be used as a medium of communication between the patient and physician. The physician will become aware of the suspected drug that may produce the ADR/AE and may cause harm to the patient. This program will minimise the frequency of re- administration of the suspected drug that may leads to adverse event. This is a step towards minimisation of Medication Error as well as Patient Safety.

(Please provide the correct information so that we would be able to serve you better)

Date *

Full Name *

Street Address *

City

State/Province

ZIP / Postal Code

Country

Phone *

Email Address *

Personal Details

Patient Initials

Gender

MaleFemaleOtherGender

Age

Medication History

Name of disease (Suffered in past) *

Drug Taken *

Side effect/ Adverse drug reaction/ adverse event *

Current Medication

Existing Disease *

Drugs used for the treatment *

Side Effect/ Adverse Drug reactions/ Adverse events *

Adverse event disappeared after stoping/ withdrawing the drug

YesNoUnknownAdverse event disappeared after stoping/ withdrawing the drug

Adverse event Re-appeared after Retaking the drug

YesNoUnknownAdverse event Re-appeared after Retaking the drug

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