ADVERSE DRUG REACTION REPORTING FORM


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

Seriousness of the Reactions

Death
Life Threatening
Hospitalization
Disability
Required Impairment to prevent damage
Other Seriousness
Lab Tests
Date Lab Test

Outcomes

Fatal Outcome
Recovering
Unknown
Continuing
Recovered
Any Other Outcome

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 Separate Form for Each Drug