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MedWatch Reporting by Consumers

MedWatch is the Food and Drug Administration's (FDA) program for reporting serious reactions
and problems with medical products, such as drugs and medical devices.  Click on any question to get more detailed information on how to answer.

NOTE: The NPA will not release your personal data. We do not sell or share personal information.
See our privacy policy for more details.
 
Name:
Address:
City:
State:
Zip:
Phone:
Email:

Patient Information

*Date of birth: (mm/dd/yyyy)
*Sex: Female
Male
*Weight (lbs):

Adverse Event or Problem

*Describe event: Adverse Event (reactions/illnesses)
Product Failure
Both
*Outcomes attributed to adverse event (check all that apply): death
life-threatening
hospitalization -- initial or prolonged
disability
congenital anomaly
required intervention to prevent permanent impairment/damage
other:
*Date of event:
*Describe event or problem:
*Other relevant history such as preexisting medical conditions:

Suspect Medication(s)

*Name of medication (give labeled strength if known):
Other:
*Dosage & frequency used:
*Therapy dates: From To
*Diagnosis for use:
*Event ended after use stopped or dose reduced: yes
no
doesn't apply
*Medication Lot #
(if known):
*Event reappeared after reintroduction: yes
no
doesn't apply
*Other medications and therapy dates:
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*Click on any question to get more detailed information on how to answer.


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