Farmacovigilancia

Protegiendo tu salud

Suspected Adverse Drug Reaction (SADR) Report.

Healthcare Professional

General
Patient Data

SADR

Suspect Drug

Dose and additional data

Health
Professional Data

General
Data

Country from which you report*

* This field is required

Full Name or Initials (starting with last names)*

* This field is required

Date Of Birth

* This field is required

Assigned sex at birth*

* This field is required

Weight (kg)

* This field is required

Size (cm)

* This field is required

Description Suspected Adverse Drug Reaction(s) (SADR)*

* This field is required

Medical prescription or self-medication?

* This field is required

How long did the SADR manifest itself? (Select a start and end period)

* This field is required

Select a period indicating start date and end date.

The drug was discontinued due to SADR?

* This field is required

Was there any improvement upon discontinuation of medication?

* This field is required

Was the drug re-administered?

* This field is required

When the medication was re-administered, the SADR appeared again?

* This field is required

Was the dose reduced?

* This field is required

Did the patient recover from the SADR?*

* This field is required

Pharmacotherapy was changed?*

* This field is required

Which one?*

Did the patient take any medication to treat SADR?

* This field is required

Which one?

Trade name(*)

* This field is required

Generic name*

* This field is required

Dosage form

* This field is required

Route of administration*

* This field is required

Batch number

* This field is required

Expiration date

* This field is required

What disease or condition did the patient take the medication for?

* This field is required

Start date of administration

* This field is required

End date of administration

* This field is required

Dose of medication taken

* This field is required

Time of medication taken

* This field is required

Was the patient undergoing treatment with any other medication?

* This field is required

Which one?

Does the patient have history of allergies?

* This field is required

Which one?

* This field is required

Are there any of the following conditions?

* This field is required

Relevant data from the patient's medical history:

* This field is required

Name(s)*

* This field is required

Father’s Last name*

* This field is required

Mother’s Last Name

* This field is required

Do you want to be contacted by Pharmacovigilance?*

* This field is required

Landline

* This field is required

Cellphone number

* This field is required

E-mail

* This field is required

Alternative E-mail

* This field is required

Comments

* This field is required

Thank you for having completed our Pharmacovigilance form, shortly our specialists will contact you if requested.

If you prefer, you can call the number: 800 -Sanfer1 (800 726 3371), 24 hours a day, or write to the following e-mail: ucfarmacovigilancia@sanfer.com.mx

Farmacovigilancia

Protegiendo tu salud

Suspected Adverse Drug Reaction (SADR) Report.

Healthcare Professional

General Patient Data

SADR

Suspect Drug

Dose and additional data

Health Professional Data

GeneralData

Select a period indicating start date and end date.

Thank you for having completed our Pharmacovigilance form, shortly our specialists will contact you if requested.

If you prefer, you can call the number: 800 -Sanfer1 (800 726 3371), 24 hours a day, or write to the following e-mail: ucfarmacovigilancia@sanfer.com.mx

General
Patient Data

Health
Professional Data

General
Data