ADVERSE DRUG REACTION REPORT FORM

Report No.: _______________ Date: ________________________

PATIENTS NAME:
______________________________________________________________________

Sex: ______ Age: _______ Nationality: _____________ Room No.: __________ File No.: _______________

DIAGNOSIS: ___________________________________________________________________________

TREATMENT: __________________________________________________________________________

DRUG THAT HAS PRODUCED ADVERSE DRUG REACTION:

______________________________________________________________________________________
_

______________________________________________________________________________________
_

REACTION DETAILS:
______________________________________________________________________________________
_

______________________________________________________________________________________
_

______________________________________________________________________________________
_

SOURCE OF DRUG WITH BATCH NO.:

_____________________________________________________

DIET FOLLOWED:
_______________________________________________________________________

STEPS TAKEN TO TREAT THE ADVERSE REACTION:

______________________________________________________________________________________
_

______________________________________________________________________________________
_

______________________________________________________________________________________
_
Name of Physician: ________________________________

Signature: _______________________________________

Date: ___________________________________________

Note: Return to the Pharmacy if completed.