Farmacovigilancia

Protegiendo tu salud

Suspected adverse reaction report

Healthcare professional

Who is it?

General
Data

SADR

Suspect Drug

Dose

Professional
Data

General
Data

Country*

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Full Name or Initials (starting with last names)*

* This field is required

Date Of Birth

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Assigned sex at birth*

* This field is required

Weight (kg)

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Size (cm)

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Description of suspected adverse drug reaction (SADR)*

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Medical prescription or self-medication?

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How long the SADR lasted?

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Select a period indicating start date and end date.

The drug was discontinued due to SADR?

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Was there any improvement upon discontinuation of medication?

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Was the drug re-administered?

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

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Was the dose reduced?

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Did the patient recover from the SADR?*

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Pharmacotherapy was changed?*

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Did the patient take any medication to treat SADR?

* This field is required

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 treatment

* This field is required

End of treatment

* This field is required

Dose of medication taken

* This field is required

Time of medication taken

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Was the patient undergoing treatment with any other medication?

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Does the patient have history of allergies?

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Which ones?

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Are there any of the following conditions?

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Relevant data from patient’s medical record:

* 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

Landline

* This field is required

Cellphone number

* This field is required

E-mail

* This field is required

Alternative E-mail

* This field is required

Do you want to be contacted by Pharmacovigilance?*

* This field is required

Comments

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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 reaction report

Healthcare professional

Who is it?

GeneralData

SADR

Suspect Drug

Dose

ProfessionalData

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
Data

Professional
Data

General
Data