Patient report on suspected adverse drug reaction

If you think you, or someone else, may have had an adverse drug reaction to a Teva medicine, please report the problem by completing the form below. We will get back to you within seven working days if additional information is required.

* required fields

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

If yes please provide the reference number:

1. Your Details:

Title:*

First name:*

Surname:*

Telephone:*

or Email:*

Address:

Address 2:

Town:

County:

Postcode:

2. About the person who had the adverse drug reaction:

Who had the adverse drug reaction?

If other please specify:

Tell us more about the person who had the adverse drug reaction

Weight:

kg lb

Height:

Age:

Date of Birth:

Gender: Male Female

3. About the medicine(s) you think caused the side effect

Name of medicine*: Dosage: What was it used for? How did you get the medicine? In what form was the medicine?* When was the medicine started?* When was the medicine stopped?*

Medicine 1

Medicine 2

Medicine 3

4. Other medicines

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

Medicine	Dosage	What used for	Date started	Date stopped

5. About the adverse drug reaction

When did the adverse drug reaction start?:

Has the adverse drug reaction stopped?: Yes No Unknown

How bad was the adverse drug reaction?

How is the person who had the adverse drug reaction now?

Please describe the adverse drug reaction and any treatment received, and tell us whether the adverse drug reaction caused the person to stop taking the medicine

6. Other questions

Was a doctor, pharmacist or other health professional told about the adverse drug reaction?:
Yes No Not Known

Are you happy for Teva to contact you for more information?: Yes No

7. Doctor's Details

Please enter the name and address of your Doctor or GP surgery