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Drug Reaction Reporting Form

Form language
Patient Information
Name / Initials
Date of Birth
MM slash DD slash YYYY
Age*
Sex*
- Male
- Female
Weight
Patient Contact Details
Country
City

Suspected Drug(s) Information
Trade Name*
Active Materials*
Concentration / Strength*
Manufacturer*
Batch Number
Expiry Date
Year*
Indication for Use*
Daily Dose*
Route of Administration*
Date Started
MM slash DD slash YYYY
Date Stopped
MM slash DD slash YYYY
Duration of Use

Suspected Reaction(s) Information
Description of Adverse Reaction*
Date Reaction Started
MM slash DD slash YYYY
Did the reaction stop after stopping the drug?
- Yes
- No
- Unknown
Did the reaction reappear after stopping the drug?
- Yes
- No
- Unknown

Seriousness
Check seriousness to adverse drug reaction
- Patient Death
- Life Threatening
- Hospitalization
- Permanent Disability
- Congenital Anomaly
- Required Intervention to Prevent Damage
- Other Specify
- Non Serious
Other Specify*
Other Information
Any Lab Tests / Date
Allergy / Pregnancy / Others

Concomitant Drug(s)
Concomitant Drugs
Name Concentration Route Dose & Frequency Used for Date Started Date Stopped Batch Number

Reporter Details
Name*
Job*
Telephone / Mobile No.*
Address*
Email
Any more comments
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