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Adverse drug reaction reporting

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Name/Folder number Date of birth GenderMaleFemale

Your email

Phone

Hospital/Treatment center
Upload extra documents
Details of adverse reaction and treatment given

Date reaction started

Date reaction stopped

Recovered YesNo Not yet recovered YesNo Unknown YesNo Did the adverse reaction result in any untoward medical conditions? YesNo If yes, specify

Hospitalization YesNo Life threathening YesNo Disability YesNo Death YesNo Others (specify)

Brand name

Generic name

Manufacturer

Batch no.

Expiry date

Reason(s) for use

Daily dose

Route of administration

Date started

Date stopped

Did the adverse reaction subside when the drug was stopped (de-challenge)? YesNo Was the product prescribed? YesNo Source of drug/product Was product re - used after detection of adverse reaction (re-challenge)? YesNo

Concomitant drugs including herbal medicines taken prior to the adverse reaction

Name of drug

Daily dose

Date started

Date stopped

Reason(s) for use Did adverse reaction re-appear upon re-use? YesNo

Name

Profession

Email address

Phone number

Address

Date of report

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Home
About us
Services
- Services
- service items
Products
Pharmacovigilance
Branch locator
Get in touch
- Contact usWe are happy to help with any enquiries
- Product Complaint formReport any adverse drug reaction

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