SIDE EFFECT NOTIFICATION FORM

Notifier

Name

Title

Health Institution

Country

Patient

Initials

Age

Height (m)

Weight (kg)

Gender

Male Female

Medicinal Product Suspected

Drug

Medicinal product name

Batch number

Storage condition

Medical History and Pathologies

Other

Oncological Diagnosis

Protocol

Cure Number

Date of First Cure

Drugs

Drug Name

Date

Dosis(mg)

Duration (days)

Route of administration

Premedication

Postmedication

Side Effect

Seriousness and detailed description of the suspected side effect: (photos, biology…)

Severity

Evolution

Partnership