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ADRs Reporting Form
Home
Pharmacovigilance
Adverse Drug Reactions (ADRs)Reporting Form
For Health e Professionals (ADR-1)
Patient Detail
Male
Female
Suspected Drug
1
Capsule
Tablets
Syrup
Suppository
Sachet
Gel
Cream
Ointment
Drops
Suspension
Concomitant Drug
1
Capsule
Tablets
Syrup
Suppository
Sachet
Gel
Cream
Ointment
Drops
Suspension
Adverse Drug Reaction
Action Taken
Action Taken :
Drug withdrawn
Dose reduced
Dose increased
Dose not changed
Unknown
Not applicable
Outcome of ADR (Tick all applicable)
The patient :
Recovered
Recovering
No improvement
Fatal
Unknown
Event subsided after stopping (dechallenge) :
Yes
No
Unknown
Event reappear after reintroducing (rechallenge) :
Yes
No
Unknown
Specific antagonist or treatment used :
Yes
No
Seriousness of ADR
Seriousness of ADR (Tick all applicable)
Required Emergency Room (ER) visit
Cancer
Others
Required intervention to prevent permanent impairment/ damage
Congenital anomaly
Prolonged hospitalization more than 24 hr.
Hospitalization
Life threatening
Permanent disability
Patient died
Reporter Details
Submit Form
