Report Adverse Reaction

A. Reporter Detail:

Reporter Name :

Reporter Speciality:

Report Address:

Telephone:

Reporter Fax/Email:

Date Of Report:

B. Patient Details:

Patient Name:

Patient Age:

Patient Weight:

Patient Sex:

Patient Contact Details:

C. Suspected Drugs:

Drug Name:

Concentration:

Route:

Dose and Frequency:

Used For:

Date Started:

Date Stopped:

Batch No:

2- Drug Name:

Concentration:

Route:

Dose and Frequency:

Used For:

Date Started:

Date Stopped:

Batch Number:

3- Drug Name:

Concentration:

Route:

Dose and Frequency:

Used For:

Date Started:

Date Stopped:

Batch Number:

D. Suspected Reaction:

Drug Reaction:

Date Reaction Started:

Date Reaction Stopped:

Action Taken Towards Adverse Reaction:

Treatment Given For Adverse Reaction:

Outcome Of Reaction:

Is Reaction Stopped After Stopping The Drug:

Is Reaction Reappeared After Retaking The Drug:

E. Seriousness of adverse reaction:

Seriousness Of Adverse Reaction:

Other:

Relevant Tests/ laboratory date Including Dates:

Other Relevant History including pre-exisiting medical conditions:

F. list of other drugs taken (Please list any other drugs taken during the last month prior to the reaction):

Drug Name:

Concentration:

Route:

Dose and Frequency:

Used For:

Date Started:

Date Stopped:

Batch No:

2- Drug Name:

Concentration:

Route:

Dose and Frequency:

Used For:

Date Started:

Date Stopped:

Batch No:

3- Drug Name:

Concentration:

Route:

Dose and Frequency:

Used For:

Date Started:

Date Stopped:

Batch No:

Report Adverse Reaction

REPORTING FORM