ADVERSE DRUG REACTION REPORTING FORM


Name
Sex
Ref No
Age
Weight
Height
Drug
Strength
Frequency
Batch No
Route Admin
Date Started
Date Stopped
Dosage
Concomitant Drug
Concomitant Strength
Concomitant Frequency
Concomitant date Started
Prescribed For
Reaction Started
Recovery Started
Describe Reactions
Allergies
Pregnancy
Smoking
Hepatic Renal Problem
PreExisting Problem
Any Other History

Seriousness Of the Reactions

Death
Life Threatning
Hospitalization
Disability
Required Impairment
Other Seriousness
Lab Tests
Date Lab Test

Out Comes

Fatal Outcome
Recovering
UnKnown
Continuing
Recovered
Any Other Out Come

Reporting Person's Detials

Name
Address
Contact No
EMail
Reporter Speciality
Date

Clinician (If Not the Reporting Person)

Name
Address
Contact No
Email
Speciality
Date

Please Fill Seperate Form For Each Drug