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

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

Describe the event

AE Reported By

Contact Number

Reported date (dd/mm/yyyy)

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