ADR FORM DESIGN – pharmdelite.in

ADR REPORT FORM

Patient Details

IP No

Gender

Age

ADR Found

Adverse Event

ADR Start Date

ADR End Date

Describe Event

Ongoing Event

Suspected Drug 01

Brand Name

Generic Name

Dose (mg)

Route of Administration

Frequency (Select any one)

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Other Drug Added Drug Withdrawn Dose Increased Dose Not Changed No Action Taken

Suspected Medication 2

Brand Name

Generic Name

Dose (mg)

Route of Administration

Frequency (Select any one)

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Other Drug Added Drug Withdrawn Dose Increased Dose Not Changed No Action Taken

Suspected Medication 3

Brand Name

Generic Name

Dose (mg)

Route of Administration

Frequency (Select any one)

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Other Drug Added Drug Withdrawn Dose Increased Dose Not Changed No Action Taken

Suspected Medication 4

Brand Name

Generic Name

Dose (mg)

Route of Administration

Frequency (Select any one)

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Other Drug Added Drug Withdrawn Dose Increased Dose Not Changed No Action Taken

Suspected Medication 5

Brand Name

Generic Name

Dose (mg)

Route of Administration

Frequency (Select any one)

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Other Drug Added Drug Withdrawn Dose Increased Dose Not Changed No Action Taken

Case File Url

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Additional Information (If Any)

ADR Reporter Details

ADR Reporter Name

Designation

Contact No

Developed by

C.D.Shakthivel

Vth Year Pharm.D

COP, SRIPMS – Coimbatore