Pharmacovigilance

Notifier

Name *
Specialty *
Adress *
Phone *
Fax *
E-mail *

Patient

Initials *
Date of birth *
Or age *
Size *
Weight *
Sex *

Medical background / allergies / tabacco / alcohol

Tobacco *
Quantity *
Alcohol *
Quantity *
Allergy *
Specify *
Medical background*

medecament teriak suspect

Drug

N° Lot

 Dose per intake and frequency Way Date of administration Period Indication(s)
Start End
Has the patient already been treated with the medication?

THERAPEUTIC DECISION (check box (es))

Specify
HAS THE ADVERSE EFFECT IMPROVED AFTER STOP / DECREASE IN THE DRUGS OF THE MEDICINAL PRODUCT?
If the drug was stopped, was it reintroduced?
If so, has the adverse effect reappeared?
Other suspect drugs
Drug Dose per intake and frequency Way Date of administration Period Indication(s)
Start End
Associated Medicines
Drug Dose per intake and frequency Way Date of administration Period Indication(s)
Start End
Treatment of adverse reaction
Drug Dose per intake and frequency Way Date of administration Period Indication(s)
Start End

Unwanted event(s)

 

 Gravity criterion Medication Relation / undesirable effect Evolution
Unwanted event 1
Alternative Etiology :
Date of occurrence Healing Date
Time of ppearance : period :
Unwanted event 2
Alternative Etiology :
Date of occurrence Healing Date
Time of ppearance : period :
Unwanted event 3
Alternative Etiology :
Date of occurrence Healing Date
Time of ppearance : period :
Description - Clinical Evolution
Biological tests
Date / Hour Test Results units Normals
Additional tests
Date Reviews Results / Comments
Security code
*Required fields
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  • Contact Teriak :

Headquarters address : 25, Rue 8603 -

Z.I. La Charguia 1 - 2035 Tunis Carthage, Tunisie

Tel : (+216) 71 772 000

Fax : (+216) 71 808 467

E-mail :pharmacovigilance@teriak.com

  • Contact Medicis :

Headquarters address : 25, Rue 8603 -

Z.I. La Charguia 1 - 2035 Tunis Carthage, Tunisie

Tel : (+216) 71 809 321

Fax : (+216) 71 809 320

Tel PV: +(216) 71 804 210

E-mail : PV@teriak.com