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Reporter Information
1. Patient Details
2. Suspected reaction(s)
3. Date reaction(s) started
4. Duration of the reaction(s)
5. Patient history of any reaction including allergies
6. Patient medical history
7. Did the reaction(s) improve when the drug was discontinued?
8. Did the reaction(s) reappear when the drug was readministered?
9. Outcome
10. Did the reaction(s) lead to hospitalization?
11. Paraclinic findings related to the reaction(s)
12. Suspected medicine(s)
13. Medications taken at the time of ADR
Additional relevant information:
NOTE: The “potency” refers to the amount of active ingredient in the pharmaceutical dosage form (e.g. 100 mg Tablet …)