Reporter Information:
Occupatoin:
Adress:
1.Patient Details:
Patient adress:
Sex:
Pregnant:
Breast Feeding:
2. Suspected reaction(s):
Please describe the reaction(s) and any treatment given:
3.Date reaction(s) started:

4. Duration of the reaction(s):

5. Patient history of any reaction including allergies:
6. Patient medical history:
7. Did the reaction(s) improve when the drug was discontinued?
8. Did the reaction(s) reappear when the drug was readministered?
9. Outcome:
10. Did the reaction(s) lead to hospitalization?
11. Paraclinic findings related to the reaction(s):
12. Suspected medicine(s):
Medicine Dosage form & potency* Daily dosage Route Indication Date started Date discontinued Manufacturer Batch No.
13. Medications taken at the time of ADR:
Medicine Dosage form & potency* Daily dosage Route Indication Date started Date discontinued Manufacturer Batch No.
Additional relevant information:
* The “potency” refers to the amount of active ingredient in the pharmaceutical dosage form (e.g. 100 mg Tablet …)