Adverse Reaction Reporting Form

A. Reporter details

B. Patient details

C. Suspected drug(s)

Drug name (Generic & Trade):

D. Suspected reaction(s)

Please describe the reaction(s):

Action taken towards AR: Drug withdrawnDose reducedDose increasedDose not changedUnknown

Treatment given for AR (if any):

Outcome of the reaction: RecoveredRecoveringNo improvementUnknown

Does the reaction Stopped after stopping the drug? YesNoI don’t know

Does the reaction Reappeared after retaking the drug? YesNoI don’t know

E. Seriousness of adverse reaction

Patient DiedLife threateningHospitalizationProlonged hospitalizationCongenital AnomalyPermanent DisabilityRequired intervention to prevent damageOther, Specify:

Other relevant History, including pre-existing medical conditions (e.g. allergies, pregnancy, smoking, renal dysfunction etc):

F. List of other drugs taken:

Drug name (Generic & Trade):