Patient Initial:
Age:
Weight:
Height:
Gender: MaleFemale
Pregnancy: NoYes
Week:
Generic Name:
Scientific Name:
Daily Dose:
Indication:
Batch Number:
Date:
From:
To:
Adverse Event Onset Date:
Describe the Reaction:
Did Reaction Disappear?
YesNoDon’t Know
Patient Status
RecoveredRecoveringNot recoveredUnknown
Tick appropriate box with reference to the adverse drug reaction (if applicable): Require hospitalizationProlonged hospitalizationLife threateningCongenital anomalyRequired intervention to prevent permanent impairment / damagePermanent disabilityDeathOther
Death Date:
Other:
Concomitant drugs (exclude drugs used to treat reaction) and medical history any diseases that the patient has (for example: Diabetes, Hypertension, etc...)
Drug Name:
Name:
Phone / Mobile:
Email:
Address:
Report Source:
PatientDoctorPharmacistOther
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