ADRs Reporting Form

Adverse Drug Reactions (ADRs)Reporting Form
For Health e Professionals (ADR-1)

Patient Detail

Suspected Drug

Concomitant Drug

Adverse Drug Reaction

Action Taken

Action Taken :

Outcome of ADR (Tick all applicable)

The patient :

Event subsided after stopping (dechallenge) :

Event reappear after reintroducing (rechallenge) :

Specific antagonist or treatment used :

Seriousness of ADR

Seriousness of ADR (Tick all applicable)

Reporter Details