Actover - ADR

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

Breastfeeding:

Yes

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

8. Did the reaction(s) reappear when the drug was readministered?

Answer:

Do not know or not done

Yes

9. Outcome

Answer:

Death

Disability

Not yet recovered

Recovered

Other

10. Did the reaction(s) lead to hospitalization?

Answer:

Yes

11. Paraclinic findings related to the reaction(s)

Text:

12. Suspected medicine(s)

13. Medications taken at the time of ADR

Additional relevant information:

Text:

NOTE: The “potency” refers to the amount of active ingredient in the pharmaceutical dosage form (e.g. 100 mg Tablet …)