ADR

Patient Information

Identities of reporter and patient will remain strictly confidential

Name
Sex
Age
Weight (Kg)
Please enter a number from 30 to 200.
Pregnancy
Adverse Reaction / Product Quality Problem
tick appropriate box
- Adverse Reaction
- Product Quality problem
Date of onset of reaction:
Date Format: MM slash DD slash YYYY
Time of onset of reaction:

: HH

MM
Description of reaction or problem (Include relevant tests/lab data, including dates):
1. Medicines / Vaccines / Devices
Trade Name & Batch No.
(Asterisk Suspected Product)
Daily Dosage
Route
Date Stopped
Date Format: MM slash DD slash YYYY
Date Started
Date Format: MM slash DD slash YYYY
Reasons for use
Adverse Reaction Outcome
Check all that apply
- Death
- Disability
- Congenital anomaly
- Required intervention to prevent permanent impariment/damage
- Life-threatening
- Hospitalisation
Other:
Reaction abated after stopping medicine:
Event reappeared on rechallange: