Medicine Safety | Sana Pharma

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Medicine Safety

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Sana Pharma pharmacovigilance system is responsible for detection, analysis and prevention of Sana Pharma products related problems, including safety, efficacy and quality problems.

To report problems related to the effectiveness or safety of our medicinal products, please fill the attached form:

Sana Pharmaceutical Industry

Report of Suspected Adverse Drug Reactions and Product Problems
Note: Identities of reporter and patient will remain confidential

Patient info

Patient’s file No

Weight kg

Patient’s Name/or Initial

Age Year

Sex

Male

Female

Height cm

Pregnant?

yes

Which Trimester?

Suspected drug(s)
Suspected drug(s) (Brand and Generic names)	Dosage Form	Dose & Strength	Route of administration	Started on	Stopped on	Indication(s) for drug treatment
Suspected drug(s) (Brand and Generic names)	Dosage Form	Dose & Strength	Route of administration	Started on	Stopped on	Indication(s) for drug treatment
Suspected drug(s) (Brand and Generic names)	Dosage Form	Dose & Strength	Route of administration	Started on	Stopped on	Indication(s) for drug treatment
Suspected drug(s) (Brand and Generic names)	Dosage Form	Dose & Strength	Route of administration	Started on	Stopped on	Indication(s) for drug treatment

Other concomitant drug(s) (brand name) used although not suspected (exclude those used to treat reaction):

None

Other concomitant drug(s)

Suspected reactions
Suspected reactions/product problem	Date of onset	Duration of reaction
Suspected reactions/product problem	Date of onset	Duration of reaction
Suspected reactions/product problem	Date of onset	Duration of reaction
Suspected reactions/product problem	Date of onset	Duration of reaction

Comments (e.g. relevant history, allergies, previous exposure to the drug. ……….. etc).

Consequences of suspected reaction(s).

Serious:

Yes

Please indicate the seriousness of reaction(s).

Specify

Was Suspected Drug(s) Discontinued

Yes

Which drug(s)?

Did reaction(s) abate after stopping suspected drug(s)?

Yes

Unknown

Which reaction(s)?

Did reactions(s) reappear after reintroduction of suspected drugs(s)?

Yes

Unknown

Patient’s case on the day of report:

Specify

Reporter info

Reporter’s Name:

Reporter’s Source

Study

Health professional (Physician, Dentist, Pharmacist, Nurse)

Regulatory authority

Other

Specify

Office Address

Date

Month

Day

Year

P.O. Box

Phone

E-mail

Fax

For further information, please contact us at:

Sana Pharma Industries
P.O.Box:144 Amman 11934 Jordan
Office: + 962 6 5233349
Fax: + 962 6 5233349
Email: info@sana-pharma.com