Report Adverse Events

Name of NEM Laboratories product *

Nature of event *

Adverse / Side Effect Product Complaint (e.g. Defects / Malfunctions)

Patient information

Name or initials *

Sex

Age

Date of birth

Pregnant *

Yes No Not applicable

Reporter information

Full name *

Occupation

Address

Country *

Phone *

Are you also the patient? *

Yes No

Relationship with patient

Event description

Description of adverse event / side effect / other experience *

Date event first noted

Date event ended — if applicable

Current status / outcome

Outcome — other (specify)

Seriousness (tick all that apply)

Death Life Threatening Hospitalization — Initial / Prolonged Disability Congenital Anomaly Required intervention to prevent permanent impairment / damage Other medically important

Suspect drug details

Unit dose / strength & form

Indication

Dosage / unit / frequency

Route

Treatment start date

Treatment end date (or ongoing) Ongoing

Lot / batch number

Expiration date

Relevant medical history (if available)

Concomitant medicines (including self-medication / herbal)