Patient Complaint Form

Name Of MEDNEXT Drug Nature Of Event ( Check All That Apply) Adverse Event/ Side EffectPregnancy/LactationOverdoseLack Of EfficiencyMisuseAbuseProduct ComplaintMedication Error Patient Name Gender MaleFemaleOther Age

Event Description

Description of Adverse Event / Side Effect/ Any other experience such as lack of effect, Medication error What happened to the event later?/ Outcome Complete RecoveryOngoingRecoveringUnknownDiedOther

Drug Use Details

Relevent Medical History( If Available)

Reporter Information

Full Name Country Phone Address Email Are You Also the Patient? YesNo Relationship With Patient