Initials(आद्याक्षर)*
No. of ambulatory card/medical patient's history
Sex
MaleFemale
Liver disease
YesNoUnknown
Kidney disease
Pregnancy
Yes
Terms*
Weeks*
Age (at time of reaction)*
Allergy (specify the allergen)
YesNo
Weight*
Brand Name*
International Non-Patented Name*
Medicine Form*
Batch No.Batch No.*
Dosage, Frequency, Administration*
Prescribed for*
Date of Start*
Date of Stop*
Batch No.*
Description of the ADR (including any results of relevant supportive laboratory testes and other investigations)
Date of Start
Date of Stop
Did the ADR disappear after the drug was stopped?
Did the ADR reappear after the drug was reintroduced?
NoneDrug withdrawalDose reducingCo-treatment cessationMedicinal therapyNon-medicinal therapy (including surgical intervention)Other (indicate):
Treatment of ADR:
Details
Recovering without consequencesImprovement of stateState without changesDeath related to the ADRDeath not related to the ADRRecovering with the consequences (indicate):Unknown
Death*
Hospitalization – Initial or prolongedLife threateningDisabilityProlongation of outpatient therapyCongenital malformationClinically significant condition (indicate):
DoctorMedical RepresentativeProfessional belongingPharmaceuticalClinically significant condition (indicate):
Name*
Address*
Date of receipt of information about ADR*
E-mail*
Telephone/Mobile*
Date of report*
