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Adverse Drug Reactions
Drug Side Effects Form
Reporter Profile
Name
*
Phone Number
*
Date
Reporter
*
Treatment Staff
Patient
Accompany the patient
Job
*
Doctor
Nurse
Pharmacist
Other
Other:
Address
1. Patient Profile
Name
*
Age
Weight (kg)
Phone
Gender
*
Male
Female
Other
Pregnant
Yes
No
Breastfeeding
Yes
No
Address
2. The type of drug complication observed and treatment measures performed
Description
*
3. Date of onset of drug side effects
Description
4. How long has the complication lasted?
Description
5. Patient history: (Allergy, hereditary disease, enzyme deficiency, current diseases, addiction, etc.
Description
6. History of any past drug side effects for the patient
Description
7. Has the observed complication decreased after stopping the drug?
Response
Yes
No
I do not know, the medicine has not been stopped
I do not know, the drug has not been prescribed again
8. Has the complication reappeared after repeated use of the drug?
Response
Yes
No
I do not know, the medicine has not been stopped
I do not know, the drug has not been prescribed again
9. Finally a drug complication
Response
Recovery
Lack of recovery
Maim
Death
Other
Other:
10. Has the drug complication led to the hospitalization of the patient?
Response
Yes
No
11. Paraclinical drug findings related to the observed complication
Description
Relevant paraclinical test results (including: blood test results, CT scan, MRI, endoscopy, etc.) should be noted if available.
12. Medications suspected of having a complication
Note: Drug power refers to the amount of active ingredient in a drug. (For example: 50 mg ampoules, 100 mg tablets, etc.)
1
*
Medicine Name
Shape of Medicine
Daily Intake
Ways to consume
2
Consumable
Date of Use
Expiry Date
Serial Number
Factory
13. Other drugs used by the patient at the time of complication
Note: Drug power refers to the amount of active ingredient in a drug. (For example: 50 mg ampoules, 100 mg tablets, etc.)
3
Medicine Name
Shape of Medicine
Daily Intake
Ways to consume
4
Consumable
Date of Use
Expiry Date
Serial Number
Factory
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