Patient information
Name*
Age*
Weight (KG)*
Height (CM)*
Gender
MaleFemale
Suspected Drug Used
Drug Name
Batch Number
Dosage/Route/Frequency
Date Started
Date Stopped
Indication
Other Drugs taken in the last 3 months prior to the Reaction, Including OTC Products and Herbal Medicines
Route
Dosage
Adverse Drug Reaction Description
Adverse Event Explanation
Relevant Medical History, Including Allergies
Relevant Test Results
Date Reaction Started
Date Reaction Stopped
Seriousness of ADR
—Please choose an option—Patient diedInvolved or Prolonged hospitalizationInvolved persistent or Significant disabilty or incapacityLife threateningCongenital anomalyRequired intervention to prevent further damage/impairmentOther
Adverse Drug Reaction Outcome Data
Outcome
—Please choose an option—RecoveredRecoveringContinuingOther
Was the Problem Solved when Stopped using the Product?
—Please choose an option—YesNoI am still using the productI dont know
Did the Problem Reappear after the Introduction of the Suspected Drug Again?
Specific Antagonist Used
—Please choose an option—YesNo
Reporter Data: (All Data will be Kept Confidential)
Name
Mobile No
Email*
Profession (Speciality)
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Suspected Drug Product
Product Type
—Please choose an option—DrugVaccineHerbal ProductFood SupplementOther
Product Name
Dosage Form
Expiry Date
Pack Size
Manufacturer/Origin
Quality Defect Detected
Type of Quality Problems
—Please choose an option—PackagingSuspected counterfeit productProduct confusion(Caused by Name, Labeling, Design or Packagin)Questionable stabilitySuspected contaminationDefective componentsLabeling problems (Caused by printing errors/omissions)Other
More Details
Consequences
Consequence
Is the Sample Available for Analysis
Has the Manufacturer/Supplier been Informed?
Department
Organization
