A. Reporter details Name: Specialty: Address: Tel.: Fax/E-mail: Date of report: B. Patient details Name: Age / Date of birth: Weight (kg): Sex: —Please choose an option—MaleFemale Patient contact details: C. Suspected drug(s) Drug name (Generic & Trade): Conc.: Route: Dose & Frequency: Used for: Date Started: Date Stopped: Batch No.: D. Suspected reaction(s) Please describe the reaction(s): Date reaction started: Date reaction stopped: 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: Relevant tests / laboratory data including dates: Other relevant History, including pre-existing medical conditions (e.g. allergies, pregnancy, smoking, renal dysfunction etc): F. List of other drugs taken (please list any other drugs taken during the last month prior to the reaction): Drug name (Generic & Trade): Conc.: Route: Dose & Frequency: Used for: Date Started: Date Stopped: Batch No.: G. MUP member details Name: Tel.: E-mail: Scientific Office: Region: Line: Date report received: [recaptcha]
