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Al Naghi Company
ADVERSE EVENT REPORT FORM
Control No.
Date & Time
14/06/2026 01:01 AM
PATIENT INFORMATION
Patient Name
Date of Birth
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Gender
Male
Female
Pregnant
Yes
No
N/A
Height
Delivery Date
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Weight
Medical History
REPORTER INFORMATION
Name
Contact No.
Address
E-mail
Qualifications
Physician
Pharmacist
Other Health Professional
Non-Heath Professional
SUSPECTED DRUG(S)
Product Name
Lot/Batch
Expiry
Formulation
Dosage
Indication
Start Date
End Date
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ADVERSE EVENT DESCRIPTION
Description
Start Date
End Date
Seriousness
Outcome
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Medically Significant
Life-Threatening
Hospitalization
Disability/Incapacity
Congenital Anomaly
Death
Others
Unknown
Recovering/Resolving
Recovered/Resolved
Not Recovered/Not Resolved
Fatal
Others
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ACTION TAKEN
Increase Dosage
Decrease Dosage
Dose no changed
Withdrawn
N/A
Did Adverse Event (AE) stopped after stopping suspected drug?
Yes
No
N/A
Did Adverse Event (AE) reappear after restarting suspected drug?
Yes
No
N/A
OTHER INFORMATION (ie. Laboratory Data, Concomitant Medications, Past Drug History, Event Information, etc., as applicable)
FRM_12-001 Adverse Event Report Form
Information obtained in this form/website is made through the users's concent, strictly confidential and is only for exclusive use of Al Naghi and its respective registration holders. Under no circumstance that this form/website reproduced, reprinted, distibuted and/or communicated in any form other than its intended purpose.
I hereby give my consent to be contacted by Al Naghi Company or its respective registration holders.
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