ADR Reporting Form
Sri Ramakrishna Hospital
Patient Details
IP No
Gender
Age
ADR Found
Adverse Event
ADR Start Date
ADR End Date
Describe Event
Ongoing Event
Ongoing Event
Suspected Medication
Brand Name
Generic Name
Dose (mg)
Route of Administration
Frequency
Morning
Afternoon
Evening
Night
Indication
Date Started
Date Stopped
ADR
Action Taken After Prediction (Select any one)
Other Drug Added
Drug Withdrawn
Dose Increased
Dose Not Changed
No Action Taken
Additional Information (If Any)
ADR Reporter Details
ADR Reporter Name
Designation
Contact No
Submit ADR