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SUSPECT ADVERSE REACTION REPORT

Information about patient

Patient initials

Country

Date of birth

AGE YRS

SEX

DA

MO

YR

Reaction information

Consequences of ADR
PATIENT DIED	LIFE THREATENING	INVOLVED OR PROLONGED INPATIENT HOSPITALIZATION	RESULTS IN PERSISTENT OR SIGNIFICANT DISABILITY / INCAPACITY	CONGENITAL ANOMALY	OTHER MEDICALLY IMPORTANT CONDITION

date

Describe reaction(s)


Start of reaction			Finish of reaction
DA	MO	YR	DA	MO	YR

Suspect drug(s) information

Suspected drug (s) (trade name, dosage forms)

Single dose, number of doses per day

Therapeutic indications

Date of therapy initiation			Date of finishing withdrawal
DA	MO	YR	DA	MO	YR

Source of information

Name
Status
Address
Telephone /fax
Å-mail

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SUSPECT ADVERSE REACTION REPORT

Information about patient

Patient initials

Country

Date of birth

AGE YRS

SEX

DA

MO

YR

Reaction information

Consequences of ADR

PATIENT DIED

LIFE THREATENING

INVOLVED OR PROLONGED INPATIENT HOSPITALIZATION

RESULTS IN PERSISTENT OR SIGNIFICANT DISABILITY / INCAPACITY

CONGENITAL ANOMALY

OTHER MEDICALLY IMPORTANT CONDITION

date

Describe reaction(s)

Start of reaction

Finish of reaction

DA

MO

YR

DA

MO

YR

Suspect drug(s) information

Suspected drug (s) (trade name, dosage forms)

Single dose, number of doses per day

Therapeutic indications

Date of therapy initiation

Date of finishing withdrawal

DA

MO

YR

DA

MO

YR

Source of information

Name

Status

Address

Telephone /fax

Å-mail