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Reporter Information
Full Name:
Phone Number:
Date:
Occupation:
General Physician
Nurse
Pharmacist
Other
Other Occupation:
Address:
1. Patient Details
Full Name:
Age:
Weight(kg:
Phone:
Gender:
Male
Female
Other
Pregnant:
Yes
No
Breastfeeding:
Yes
No
Address:
2. Suspected reaction(s)
Text:
3. Date reaction(s) started
Text:
4. Duration of the reaction(s)
Text:
5. Patient history of any reaction including allergies
Text:
6. Patient medical history
Text:
7. Did the reaction(s) improve when the drug was discontinued?
Answer:
Do not know or not done
Yes
No
8. Did the reaction(s) reappear when the drug was readministered?
Answer:
Do not know or not done
Yes
No
9. Outcome
Answer:
Death
Disability
Not yet recovered
Recovered
Other
10. Did the reaction(s) lead to hospitalization?
Answer:
Yes
No
11. Paraclinic findings related to the reaction(s)
Text:
12. Suspected medicine(s)
Medicine:
Dosage form & potency:
Daily dosage:
Route:
Indication:
Date started:
Date discontinued:
Batch No.:
Manufacturer:
Add New Suspected Medicine Group
13. Medications taken at the time of ADR
Medicine:
Dosage form & potency:
Daily dosage:
Route:
Indication:
Date started:
Date discontinued:
Batch No.:
Manufacturer:
Add New ADR Group
Additional relevant information:
Text:
NOTE:
The “potency” refers to the amount of active ingredient in the pharmaceutical dosage form (e.g. 100 mg Tablet …)
Submit information