Adverse Drug Reactions

Drug Side Effects Form

  • Reporter Profile

  • 1. Patient Profile

  • 2. The type of drug complication observed and treatment measures performed

  • 3. Date of onset of drug side effects

  • 4. How long has the complication lasted?

  • 5. Patient history: (Allergy, hereditary disease, enzyme deficiency, current diseases, addiction, etc.

  • 6. History of any past drug side effects for the patient

  • 7. Has the observed complication decreased after stopping the drug?

  • 8. Has the complication reappeared after repeated use of the drug?

  • 9. Finally a drug complication

  • 10. Has the drug complication led to the hospitalization of the patient?

  • 11. Paraclinical drug findings related to the observed complication

  • 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.)
  • Medicine NameShape of MedicineDaily IntakeWays to consume 
  • ConsumableDate of UseExpiry DateSerial NumberFactory 

  • 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.)
  • Medicine NameShape of MedicineDaily IntakeWays to consume 
  • ConsumableDate of UseExpiry DateSerial NumberFactory 
  • Drop files here or
    Max. file size: 5 MB, Max. files: 3.

    • Other Related Descriptions