Adverse Events Form

  • Patient
  • Suspected Drug
  • Adverse Drug Reaction
  • Action Taken & Outcome
  • Reporter

Patient Name (optional):
Age:
Gender:
City:
Address:

Drug Name:
Manufacturer:
Dose Frequency:
Start Date:
End Date:

Adverse Events:
Date of Event Started:
Date of Event Disappeared:

Action Taken:


Outcome of ADR:
The Patient:

If (Patient recovered), please select the date:
Event Subsided After Stopping (Dechallenge):
Event Reappeared after Reintroducing (Rechallenge):
Specific Antagonist or Tratment Used:

If you chose (Yes), please specify:


Seriousness of ADR:
Seriousness of ADR:

If (Patient died), please select the date:

If you chose (Other), please specify:

Reporter Name:
Email:
Mobile Number:
City:
Address: