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,
institutions and patient will remain confidential. Please fill or mark all appropriate items. Please print information and accomplish
in duplicate.
*Refer at the back of the page for more details.
Patients initials Date of Birth Sex Male
Female
Weight (kg)
Height (cm)
Ethnic group:
Filipino Others __________________________

Relevant History/Diagnosis:

Describe the reaction/s:

* Labeled Unlabeled * Severity: 0 1 2 3 4 5

* Classification: A B C D E F
Date of onset: mmm/dd/yyyy _________________

Time: __________ am __________ pm
Suspect drug (s)

Indicate Generic
and Brand name

Dose Frequency Route Date/time started Date Stopped
(mmm/dd/yyyy)
Indication/s for
using the drug
Manufacturer

Include
batch/lot#
Time mmm dd yyyy
1.
2.
3.
Other drugs consumed at the same time and/or three (3) months before
1.
2.
3.
Is Traditional/Herbal drug(s) consumed at the same time and/or three (3) months before? YES NO
Treatment of reaction/s:
Outcome: (pls check)
Recovered Date: dd/mm/yr________ Sequelae? No Yes Please describe ____________________
Not yet recovered
Unknown Resulted in prolonged hospitalization? No Yes
Died Date: dd/mm/yr ________
Comments:
a. Allergies (specify)
b. Previous exposure/reaction to suspect drug/s No Yes Please describe ___________________________
c. Pregnancy (LMP )
d. Others

Name of Reporter: (PRINT)


MD RPh RN Patient Others________
Signature of Reporter: Date Reported: (mmm/dd/yyyy)
Email address:

Telephone: Fax No:
Complete address: