patient Details

Patient Initial
Age
Age Group
Gender

Suspected Product Details

Trade/generic name
Strength
indication
Dose & Rout of Administration
Duration of treatment
Batch No
Expiry Date
Drug Formulation

Description of the adverse Drug Reaction (ADR)

ADR Description
Outcome
Diagnostic, Treatment medication, Lab value that Associated with adverse event
Action has taken after ADR ?
Event Onset date
Event End Date
Were concomitant drugs taken?
drug name
indication
dose/route/frequency
start date
End Date

Reporter Details

Reporter Name
Address / Country
Telephone / mobile
Email
Occupation / specialty
Origin of Dispensing
fax
date
laoding

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