Adverse Drug Reaction Reporting Form

A. Patient Details *

Patient Name

Required

Age at time of onset (yrs)*

Required

Weight (kg)

Required

Patient Number

Required

Health Facility

Required

District

Required

Sex: M/F*

Required

Last Menstrual Period

Required

Trimester (if pregnant)

Required

B. Suspected Drug(s) Details *

Generic Name*

Required

Brand Name

Required

Dose, Route Frequency

Required

Date Started*

Required

Date Stopped

Required

Prescribed for Expiry Date

Required

Batch No

Required

C. SUSPECTED REACTIONS *

Required

Outcome

Required

Date Reaction Started*

Required

Date Reaction Stopped

Required

Date Of Notification

Required

Seriousness Of The Reaction

Required

D. Concomitant Drugs *

Please give information on the drug(s) the patient has been taking together with the suspected drug including those taken for chronic diseases (include self medication and herbal preparations);

Generic Name

Required

Brand Name

Required

Dosage

Required

Date Started

Required

Date Stopped

Required

Indication (Prescribed or OTC)

Required

E. Reporter's Details *

Name/Designation*

Required

Telephone

Required

Email Address

Required

Date of Reporting

Required

Health Facility

Required

By submitting, you consent to Qcil processing your information and storing your submitted details on our database.

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