Report an Adverse Drug Event

Suspected Adverse Drug Event Reporting Form

A). PATIENT INFORMATION
B). PRODUCT INFORMATION
C). EVENT INFORMATION
Adverse Event/ReactionQuality ProblemMedication ErrorOthers
FatalUnknownRecoveredRecoveringOther
Patient died due to reactionLife threateningCaused disability/ incapacityInvolved/ prolonged inpatient hospitalization
D). OTHER DRUG(S)/ ALTERNATIVE MEDICINE(S) AND HISTORY
E). REPORTER INFORMATION
PhysicianPharmacistNursePatientOther
A). PATIENT INFORMATION
B). PRODUCT INFORMATION
C). EVENT INFORMATION
Adverse Event/ReactionQuality ProblemMedication ErrorOthers
FatalUnknownRecoveredRecoveringOther
Patient died due to reactionLife threateningCaused disability/ incapacityInvolved/ prolonged inpatient hospitalization
D). OTHER DRUG(S)/ ALTERNATIVE MEDICINE(S) AND HISTORY
E). REPORTER INFORMATION
PhysicianPharmacistNursePatientOther