Adverse Drug Reaction Form

Confidentiality and Data Protection
We assure you that all personal information provided will be treated with the highest level of confidentiality and used solely for pharmacovigilance purposes.

PATIENT’S DETAILS

Full Name or Initials:

Patient Record No:

Date of Birth:

Gender:

M: F:

Weight(kg):

Hospital/Treatment Centre:

ADVERSE DRUG REACTION (ADR)

DESCRIPTION

OUTCOME OF REACTION

TICK AS APPROPRIATE

Congenital Abnormally Life-threatening

Recovered fully Recovered with disability

Death Others (specify)

DATE Reaction Started

Is the reaction still ongoing?

Yes No

DATE Reaction Stopped

Was the patient Admitted Due to ADR

Yes No

If already Hospitalized, was it prolonged due to ADR

Yes No

Duration of Admission (days):

Treatment of Reaction:

SUSPECTED SWIPHA DRUG

(Including Biologicals Medicines & Nutraceuticals)

DRUG DETAILS

(State name and other details if available / Attach product label / Sample (if available)

Brand Name:

Generic Name:

Batch No:

NAFDAC No:

NAFDAC NO does not exist for the selected brand name

Expiry Date:

Name & Address of Manufacturer:

Indications for Use

Dosage

Route of Administration

Date Started

Date Stopped

CONCOMITANT MEDICINES

(All medicines taken within the last 3 months including Nutraceutical and self-medication)

Brand/Generic

Dosage

Route

Date Started

Date Stopped

Reason for Use

SOURCE OF REPORT:

Name of Reporter:

Address:

Profession:

Telephone:

Email Address:

I hereby consent to the collection, use and recording of my information for the purposes of pharmacovigilance and ADR follow-up
I agree to be contacted if additional information about this ADR is required.

NAVIGATION

SOCIAL MEDIA

CONTACT