Adverse Drug Reaction (ADR) Reporting

Adverse Drug Reaction (ADR) Reporting Form

A.Patient Details

Patient initials
Date Of Birth
Weight (kg)
Height (cm)
B. Suspected Drug/s
Suspected Drugs Name
Suspected Manufacturer & Batch No.
Start Date
Dose Route
Purpose Of Use
C. Concomitant Drug/s (Exclude those used to treat reaction)
Concomitant Drugs Name
Concomitant Manufacturer & Batch No.
Start Date
End Date
Dose Route
Purpose Of Use
D. Adverse Drug Reaction Description
Adverse event including relevant tests/lab data and dates Other relevant history, including preexisting medical conditions;(Diagnosis, allergies, pregnancy, hepatic, renal etc
Date when event started
Date when event end
E. Action Taken
Action Taken
F. Outcome of ADR
Specific antagonist used
Event reappeared after reintroducing to the suspected drug (Rechallenge)
Event subsided after stopping the suspected drug (Dechallenge)
G. Seriousness of ADR
Seriousness Of ADR

H. Reporter Details

Reporter Name
Reporter Address
Reporting Date
Phone No