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Patient
Suspected Drug
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Reporter
Patient Name (optional):
Age:
Gender:
Male
Female
City:
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Abyan
Aden
Al-Baidaa
Al-Dalee
Al-Hodaidah
Al-Jawf
Al-Mahrah
Al-Mahweet
Amanat Al-Asemah
Amran
Dhamar
Hadramowt
Hajja
Ibb
Lahj
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Saada
Sanaa
Shabwa
Soqotra
Taiz
Address:
Drug Name:
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End Date:
Adverse Events:
Date of Event Started:
Date of Event Disappeared:
Action Taken:
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Drug withdrawn
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Unknown
Outcome of ADR:
The Patient:
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Patient recovered
Patient recovering
No improvement
Fatal
Unknown
If (Patient recovered), please select the date:
Event Subsided After Stopping (Dechallenge):
Yes
No
Unknown
Event Reappeared after Reintroducing (Rechallenge):
Yes
No
Unknown
Specific Antagonist or Tratment Used:
Yes
No
Unknown
If you chose (Yes), please specify:
Seriousness of ADR:
Seriousness of ADR:
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Patient died
Life threatening
Permanent disability
Hospitalization
Prolonged hospitalization
Congenital anomaly
Required intervention
Required emergency room
Cancer
Other
If (Patient died), please select the date:
If you chose (Other), please specify:
Reporter Name:
Email:
Mobile Number:
City:
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Abyan
Aden
Al-Baidaa
Al-Dalee
Al-Hodaidah
Al-Jawf
Al-Mahrah
Al-Mahweet
Amanat Al-Asemah
Amran
Dhamar
Hadramowt
Hajja
Ibb
Lahj
Mareb
Rayma
Saada
Sanaa
Shabwa
Soqotra
Taiz
Address: