Adverse Drug reaction Reporting Form

A- Patient Details






B- Suspected Drugs

Drug Name Concentration Used For Dose Route Date Started Date Stopped Batch Number


C- Suspected Reaction(s)









D- List of other drugs taken (Please list any other drugs taken during the last month prior to the reaction -other than the suspected drug/s )

Drug Name Concentration Used For Dose Route Date Started Date Stopped Batch Number


E- Reporter Details









F- Any More Comments



G- Report To


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