The form
for reporting adverse drug reactions

* required fields

  • 1) PATIENT INFORMATION

    Please provide at least one answer about the patient.
  • 2) CONTACT INFORMATION FOR THE PERSON SUBMITTING

    Please state full name and telephone number or email address of the person submitting the form.
  • 3) INFORMATION ABOUT ADVERSE EFFECTS OF THE MEDICATION

  • 4) INFORMATION ABOUT MEDICATION(S) SUSPECTED TO HAVE CAUSED ADVERSE EFFECTS

  • 5) IMPORTANT INFORMATION

  • 6) OTHER MEDICATION USED (drugs interacting with the suspected medication should be listed in Table 4)

  • *C – medication administered at the same time; T – medication administered to combat adverse effects; P – medication withdrawn before adverse effects were observed
  • 7) MEDICAL HISTORY: PAST AND CURRENT ILLNESSES