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Adverse Event Reporting
Your Name
1. Particulars of Patient
Patient Name/Initials
Patient Age
Patient Weight (Kg)
.
Male
Female
Pregnant
Not Pregnant
Patient Address
Relevant Medical History
2. Adverse Event
Reason for reporting:
*
Requires or prolongs hospitalization
Permanently disabling or incapacitating
Congenital anomaly
Life threatening
Death
Overdose
Other
3. Suspected Drug
Name of suspected drug
Generic Name (molecule)
Manufacturer
Batch/Lot #/Expiry/Serial
Route of administration
Starting date of medication (dd/mm/yyyy)
Duration of event
Date of discontinuation of drug because of event (dd/mm/yyyy) or ONGOING TREATMENT
4. Event
Describe the event
5. Reporting Physician / Pharmacist
AE Reported By
Contact Number
Reported date (dd/mm/yyyy)
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