Confidential Report on Adverse Drug Experience  
     
  Note: Submission of this report does not constitute an admission that the drug caused the adverse reaction. Identities of the reporter, institution and patient will remain confidential. Please fill/mark all appropriate items.  
     

Patient's initials:

Age:

Gender:

Weight (kg):

   Ethnic group:

M F

 
Chinese   Indian   Filipino  
American   Eurasian   Others  
 

Describe the reactions:

   Date of onset Time

 
Am Pm
 
Suspect drug(s):
Indicate generic and brand names		 Dose Frequency Route Date Started Date Stopped Indications for
using the drug 		Manufacturer
Include: Batch/Lot#
 

Other drugs consumed at the same time and/or three (3) months before
 
 

Treatment of reactions
 

Outcome    
Recovered  
Date: dd/mm/yyyy
Not yet recovered    
Unknown    
Died  
Date: dd/mm/yyyy
Resulted in prolonged hospitalization?
Yes No
 
Sequelae
Yes No
Please describe:

 
Comments    
allergies (specify)    
previous exposure/reaction
to suspect drug/s
Yes No
Please describe:
pregnancy with LMP    
relevant history    
others    
 
Name of reporter: Date reported:
MD RPh RN Patient Others
 
 
Email address: Telephone:
 
Complete address: Fax: