Suspected Adverse Reaction Form

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SUSPECTED ADVERSE DRUG REACTION REPORTING FORM

Please fill this form if you or anyone else you know may have had an Adverse to one of our Therapeutic Goods (Medicine/Medical Device/Alternative Medicine)

Patient's Name *

Father's Name *

Date of Birth *

Sex *MaleFemaleOther

Patient's CNIC *

Patient's Email Address

Patient's Contact Number *

Address *

Apartment, suite, etc

City *

State/Province

ZIP / Postal Code

Country

Reporter's Name *

Relation to Patient *

Reporter's CNIC *

Reporter's Email Address

Reporter's Contact Number *

Address *

Apartment, suite, etc

City *

State/Province

ZIP / Postal Code

Country

Describe the reaction(s) *

Describe the Incident that lead to this conclusion *

Medicine Start Date *

Medicine End Date *

Duration of Treatment *

Outcome of the Reaction *

DeathLife ThreateningDisabling/IncapacitatingCaused/prolonged hospitalizationCongenital anomaly/birth defectOther medically important condition

Therapeutic Product *

Dosage *

Period since in use *

Other Therapeutic Product

Dosage

Period since in use

Other Therapeutic Product

Dosage

Period since in use

Full Name of Medicine on the Package *

Manufacturer *

Batch # *

Date of Manufacturer *

Date of Expiry *

Current Status of Medicine *Still in useStopped/Changed

Details of all the medicines being taken by the patient *

Details of illness for which the treatment is being done. *

Upload Prescription of the Patient

Drag and Drop (or) Choose Files

Consent *

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