If you have observed / suffered some side effect of any medicine, please give detail in the following format.

 

As a responsible citizen, your information will help us to compile the data observed worldwide and will help the society to overcome the adverse reactions / side effects and their preventive measure for the benefit of the society at large.



FEEDBACK FORM
For voluntary reporting of suspected adverse drug reactions / side effects.
Please express your observations even if you are not sure or certain.
The data shall be used for research and statistical purposes only.
Give maximum possible information or leave blank if not known.
(*Marked columns are mandatory.)

 

 

Drug Side Effects

(So that the research fellow may contact you, if required.)
(So that the research fellow may contact you, if required.)

Patient Details

Medicine Details

(कितनी मात्रा कितने दिनों तक सेवन की गयी ।)
(Approximate Date/Month/Year, when Medicine was used (may be back-date)

Suspected Side Effect / Adverse Drug Reactions

क्या दुष्प्रभाव महसूस किया गया कृपया लिखें ।
( साथ साथ कोई और दवा का सेवन किया गया हो तो लिखें ।)
( पूर्व में हुई सर्जरी अथवा चिकित्सा कि जानकारी हो तो लिखें । )
( दवा बंद करने के बाद दुष्प्रभाव ठीक हो गए या ठीक करने के लिए दवा लेनी पड़ी या ठीक ही नहीं हुई इत्यादि संबंधी जानकारी लिखें । )

Mission Bharat Mata