Adverse Drug Reaction Reporting Form

Patient Details

Patient Initial

Age

Age Group*

Gender*

Suspected Product Details

Trade/Generic Name*

Strength*

Indication

Dose & Rout Of Administration*

Duration Of Treatment

Batch No

Expiry Date

Drug Formulation*

Description of the adverse Drug Reaction (ADR)

ADR Description*

Outcome*

Diagnostic, Treatment Medication, Lab Value That Associated With Adverse Event

Action Has Taken After ADR ?

Event Onset Date

Event End Date

Were Concomitant Drugs Taken?

If yes, please provide more details on the drug (name, dose, and indication)

Origin Of Dispensing

Reporter Details

Reporter Name*

Address / Country

Telephone / Mobile

Email*

Occupation / Specialty

Fax

Date