Patient Initials*
Country*
Date of Birth*
Age By Year*
Month*
Weight (kg)
Height (cm)
Patient Address
Sex*MaleFemale
Pregnant*YesNoNot applicable
Pregnancy Week
Date of Reaction Started
Date of Recovery
Describe the Reaction(s) or problem*
Tick appropriate box with reference to the adverse drug reaction:
Life threateningDeathCongenital anomalyRequires or prolongs hospitalizationPermanently disabling or incapacitatingOther medically important condition
If Other, Please Specify
Select applicable outcome:*
Fatal (Death)RecoveringRecoveredContinuingUnknownOther (Specify below)
Brand Name (JP Product Only)*
Generic Name
Manufacturer
Batch No.
Strength*
Dose(Amount Of Medicine Taken)*
Route*
Dosage Form*
Purpose of Use (Indication)
Duration of Treatment
Drug Discontinued or Dose Reduced
Reaction stopped after drug discontinuationYesNoNA
Reaction reappeared after re-administrationYesNoNA
Concomitant medical product including self-medication and herbal remedies with therapy dates (exclude those used to treat the reaction)*:
Other relevant history including pre-existing medical conditions (e.g., allergies, race, pregnancy, smoking, alcohol use, hepatic/ renal dysfunction etc.)
Have you experienced the same side effect before?YesNo
Name*
Qualification*
Reporter Organization
Address
Town
State or Province
Phone No.*
Email
Secondary Reporter Name
Qualification
Organization
Country
Province
Phone No.
Causality Assessment: (To be assigned by HCP only.)
CertainPossibleProbableNot relatedUnassessableUnknown
Date of this Report
The patient’s identity is held in strict confidence and fully protected. Jamjoom staff is not expected to and will not disclose the reporter’s identity in response to a request from the public.
By providing your data, you consent to the collection, processing, and submission of your information to regulatory authority, when required.
You acknowledge that your data will be handled in accordance with applicable data protection and privacy laws and may be shared with the authorized entities.
This data will be retained for a period of 10 years for regulatory compliance and related purposes.
Submission of a report does not constitute an admission that medical personnel or manufacturer or the product caused or contributed to the reaction.
