Adverse Drug Reaction Reporting Form

Date of Event

Reporter Details

Patient Information

Adverse Drug Reaction

Death
Life - threatening
Disability
Hospitalization- initial
Congenital abnormality
Hospitalization - prolonged
Others

Outcome of the ADR

Resolved
Lost to follow-up
Unknown
Death

Suspected medication

Concomitant medication(s)

Action taken to treat ADR

Medical treatment
Drug Stopped
Drug Reduced

Medical history

Laboratory data

Additional information

Adverse Drug Reaction Reporting Form

Date of Event
Reporter Details
 
Patient Information
KG LB
Male Female
CM FT
 
Adverse Drug Reaction
Yes No
Death
Life - threatening
Disability
Hospitalization- initial
Congenital abnormality
Hospitalization - prolonged
Others
 
Outcome of the ADR
Resolved
Lost to follow-up
Unknown
Death
Yes No
Yes No
 
Suspected medication
 
Concomitant medication(s)
 
Action taken to treat ADR
Medical treatment
Drug Stopped
Drug Reduced
Yes No
 
Medical history
Yes No
 
Laboratory data
 
Additional information