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Adverse drug reaction reporting form

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Confidential Information

The information supplied by you will contribute to the overall improvement of drug safety and therapy

1. Patient Information
2. Suspected Adverse Reaction (s)/ Side effect (s)
3. Any relevant Medical / Social History.
4. Suspected substance/medicinal product (s) (Medicine/ Product Name, Manufacturer, Batch /Lot no, Route (s) of administration, Daily dose, Start Date, Stop Date)
5. Other medicines currently being used by the patient
6. Past medication history (List all medicines used in the last 3 months including herbals, if pregnant indicate medicines used in the 1st trimester)
7. De-challenge/Re-challenge
8. Any laboratory investigations/ tests done and Results
9. Grading of the adverse reaction /side effect
10 Has this Suspected Adverse Reaction (s)/ Side effect (s) been reported to your doctor?
11. Your effort in filling this form is greatly appreciated. Kindly provide your details below.
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