REPORTING FORM FOR SUSPECTED ADVERSE REACTIONS TO MEDICINES/COMPLEMENTARY PRODUCTS/ MEDICAL DEVICES


PATIENT INFORMATION

BHT / Prescription no. / Record no.
Email
Name / Initials *
Address
Age *
Weight - Kg
Gender *

Ethnicity

SUSPECTED MEDICINE

Generic Name *
Trade Name
Batch No
Expiry Date
Indication / Reason for use *
Name of the manufacturer*
Address of the manufacturer
Dose *
Frequency
Route of administration *

Therapy Dates
Date Begun
Date Stopped

OTHER MEDICINES TAKEN AT TIME OF REACTION WITH THERAPY DATES (EXCLUDE TREATMENT OF EVENT)

DETAILS OF THE ADVERSE REACTION

Date of onset of event *
Date of this report
System involved

Time deference between the last dose and the onset of reaction
Describe event *
Lab investigations if any
Do you consider the reaction to be serious *    
If yes please tick why the outcome of the adverse event is serious



Result on discontinuation of suspect drug
Alternative diagnosis
Result on reintroduction of drug Reappeared
Risk factors present

REPORTING DOCTOR/ PHARMACIST/ NURSE/DENTIST/ OTHER

Name *
Designation *

Address
Telephone Number *
Institute *
Institute Name *
Email
Date of reporting