Healthcare Professional report on suspected adverse drug reaction

If you suspect that your patient has had an adverse drug reaction which may be related to the Teva medicine they are taking, please submit this form and we will get back to you within seven working days.

* required fields

Did you contact Teva previously about this adverse event?*: Yes No

If yes please provide the reference number:

Did you report the event to MHRA: Yes No

If yes please provide the MHRA reference number:

1. Reporter's (Your) Details:

Title:*

First name:*

Surname:*

Telephone:*

or Email:*

Address:

Address 2:

Town:

County:

Postcode:

Country :

Profession:*

2. Patient Details:

Initials
(given name, surname):*

Age:

Date of Birth:*

Gender:* Male Female

Weight:

kg lb

Patient Identification Number
(if available):

3. Suspected drug(s)

Brand name of drug*: Batch number if known Route of administration Dosage: Date started Date stopped Prescribed for

Medicine 1

Medicine 2

Medicine 3

4. Other medicines

Please tell us about any other medicines or remedies used within three months of having adverse reaction(s).

Medicine (brand/generic name)	Dosage (specifiy units)	Perscribed for (eg diabetes)	Date started (dd/mm/yy)	Date stopped (dd/mm/yy)

5. Suspect Reaction(s)

Reaction:*

Date Started:

Date Stopped:

Outcome*

Did the patient require hospitalisation? Yes No

If yes please provide dates from: to:

Any further reaction details?

Do you consider the reaction to be serious? Yes No Unknown

Did the patient die? Yes No Unknown

Was the reaction life-threatening? Yes No Unknown

Was the patient incapacitated or disabled? Yes No Unknown

Did a congenital abnormality occur? Yes No Unknown

Did you consider the reaction medically significant? Yes No Unknown

6. Other information

Please add any further medical history, test results, known allergies, rechallenge(if performed), suspected drug interactions.