Adverse Event Reporting

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Reporter Details
Name
Telephone Number
Cityyour full name
Patient’s Details
Gender
Age
Weight
Telephone
Medicine Details
Name of Medicine
Strength (i.e. mg etc)
Manufacturer
Batch/Lot number
Expiry Dateof appointment
Doseyour full name
Dose Frequencyyour full name
Indication/Use
Route of Administration( i.e. Oral, injection etc)
Start Date of Useof appointment
Duration over which medicine was taken/ used (Specify in days, weeks or months)your full name
Was this medicine prescribed by a doctor/physician?
Were other medicines taken concurrently with the suspect medicine above?
If yes, specify (Name of medicine (s), strength, dose, indication)your full name

Adverse Event Details

Seriousness of Adverse Event

Seriousness of Adverse Eventpick one!
Adverse Event Start Date
Duration Adverse Event has Lasted (specify in hours, days, weeks etc)your full name

Action Taken

Languagepick one!

Outcome of Action Taken

Languagepick one!
I do hearby provide consent to have followup done
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