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COMPANY
ACCREDITATION
CAREERS
PRINCIPLES
WHO WE ARE
CONTACT
HEALTH CONNECT
PATIENTS
PRESCRIBERS
PROGRAMS
SERVICES
ADHERENCE
ASSISTANCE PROGRAM
CUSTOMIZED MEDICATION PACKAGING
IMMUNIZATION
INSURANCE
MENTAL HEALTH
MY CARE
ORPHAN THERAPIES
ONE EXPRESS
OTC MEDICATION
PET MEDICATION
PERSONALIZED MEDICATION MANAGEMENT
PRESCRIPTION BUNDLE PROGRAM
RX ASSIST
SMOKING CESSATION
SPECIAL AUTHORIZATION
STRESS MANAGEMENT
MEDICAL CONDITIONS
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ADVERSE EVENT REPORTING
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Date of Birth
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Age (Years)
Sex
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N/A
Reaction Onset
Description of the Event
Check All Appropriate to Adverse Reaction
Patient Died
Involved or prolonged patient hospitalization
Involved persistent or significant disability or incapacity
Life threatening
Suspected Drug(s) (Include generic name)
Daily dose(s)
Route(s) of administration
Indication(s) for use
Therapy date start
Did reaction abate after stopping the drug(s)?
Yes
No
N/A
Therapy duration
Did reaction reappear after reintroduction?
Yes
No
N/A
Concomitant drug(s) and dates of administration (exclude those used to treat reaction)
Other relevant history (e.g. diagnostics, allergies, pregnancy with last month of period, etc.)
Name and address of manufacturer
Production date
MFR control number
Expiration date
Report Source
Study
Literature
Health professional
Report Type
Initial
Follow Up
N/A
