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Pharmacovigilance
Formulaire
Formulaire
Treated patient
Products
Practitioner declaring
Doctor prescriber
Effect
Severity
Evolution
Treated patient
Step 1
Gender*
Female
Male
Is it a newborn?*
Yes
No
Products have been taken :
By the newborn
During breastfeeding
By pregrant mother
Trimester of pregnancy
1
st
trimester
2
nd
trimester
3
rd
trimester
Next
Products
Step 2
Has any product (s) been interrupted ?*
Information not available
Yes
No
Disappearance of the reaction after stopping one or more products ?*
Information not available
Yes
No
Have any of the products been reintroduced ?*
Information not available
Yes
No
Reappearance of the reaction after reintroduction of one or more products ?*
Information not available
Yes
No
Previous
Next
Practitioner declaring
Step 3
Quality*
Doctor
Pharmacist
Dentist doctor
Other
Previous
Next
Doctor prescriber
Step 4
Is he a declaring doctor?*
Yes
No
Previous
Next
Effect
Step 5
Previous
Next
Severity
Step 6
How serious ?*
Hospitalization or prolongation of hospitalization
Permanent incapacity or invalidity
Life threatening
Previous
Next
Evolution
Step 7
What is the evolution?*
Healing without sequelae
healing with sequelae
Death due to effect
Death to which effect may have contributed
Death unrelated to effect
Subject not yet reinstated
Unknown
Previous
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