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Suspected Adverse Drug Reaction Reporting Form

[[[[“field35″,”equal_to”,”Yes”]],[[“show_fields”,”field47″]],”and”],[[[“field47″,”contains”,”Other”]],[[“show_fields”,”field62″]],”and”],[[[“field93″,”equal_to”,”Yes”]],[[“show_fields”,”field109,field110,field107,field84,field105,field14,field80,field101,field17,field100,field99,field98,field74,field70,field95,field73″]],”and”],[[[“field73″,”equal_to”,”Yes”]],[[“show_fields”,”field66,field9,field10,field108,field13,field106,field104,field79,field103,field77,field76,field65,field97,field96,field58,field113″]],”and”],[[[“field113″,”equal_to”,”Yes”]],[[“show_fields”,”field114,field115,field116,field117,field118,field119,field120,field121,field122,field123,field124,field125,field126,field127,field128,field129″]],”and”],[[[“field129″,”equal_to”,”Yes”]],[[“show_fields”,”field144,field143,field142,field141,field140,field139,field138,field137,field136,field135,field134,field133,field132,field131,field130″]],”and”],[[[“field47″,”equal_to”,”Death”]],[[“show_fields”,”field182″]],”and”],[[[“field145″,”equal_to”,”Yes”]],[[“show_fields”,”field161,field160,field159,field158,field157,field156,field162,field163″]],”and”],[[[“field163″,”equal_to”,”Yes”]],[[“show_fields”,”field180,field179,field178,field177,field176,field175,field174,field181″]],”and”],[[[“field181″,”equal_to”,”Yes”]],[[“show_fields”,”field185,field186,field187,field188,field189,field190,field191,field192″]],”and”],[[[“field192″,”equal_to”,”Yes”]],[[“show_fields”,”field199,field198,field197,field196,field195,field194,field193″]],”and”],[[[“field47″,”equal_to”,”Other”]],[[“show_fields”,”field62″]],”and”]]
1 A. Patient Information
2 B. Suspected Adverse Reaction
3 C. Suspected Medication(S)
4 D. Reporter Details
Select genderpick one!
Causality AssessmentCausality Assessment
Action taken (Please Tick)Please Tick
Reaction reappeared after reintroduction (Please Tick)Please Tick
Add second suspected medicationPlease Tick
Causality AssessmentCausality Assessment
Action Taken (Please Tick)Please Tick
Reaction Reappeared After Reintroduction (Please Tick)Please Tick
Add third suspected medicationPlease Tick
Causality AssessmentCausality Assessment
Action Taken (Please Tick)Please Tick
Reaction reappeared after reintroduction (Please tick)Please Tick
Add fourth suspected medicationPlease Tick
Causality AssessmentCausality Assessment
Action Taken (Please Tick)Please Tick
Reaction reappeared after reintroduction (Please tick)Please Tick
Add fifth suspected medicationPlease Tick
Causality AssessmentCausality Assessment
Action Taken (Please Tick)Please Tick
Reaction reappeared after reintroduction (Please tick)Please Tick
Concomitant medical product including self-medication and herbal remedies with therapy dates (exclude those used to treat reaction)
Add second concomitant medical productPlease Tick
Add third concomitant medical productPlease Tick
Add fourth concomitant medical productPlease Tick
Add fifth concomitant medical productPlease Tick
Seriousness of the reactionSeriousness of the reaction
Reason of SeriousnessReason of Seriousness
OutcomesOutcomes
Confidentiality: The patient’s identity is held in strict confidence and protected to the fullest extent. Submission of a report does not constitute an admission that medical personnel or manufacturer or the product caused or contributed to the reaction. Submission of an ADR report does not have any legal implication on the reporter.
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