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ADR Form for health care professionals

Required Information


ABOUT PATIENT

For Office Use Only
Report No.




AgeDOB


yearsmonthsdays

Kglbs


MaleFemale




ABOUT PROBLEM


Adverse EventProduct Use ErrorProduct ProblemProblem with different manufacturer of same medicine
Death (include date)

Life-threateningHospitalization - initial or prolongedDisability or Permanent DamageCongenital Anomaly/Birth DefectsOther Serious (Important Medical Events)




The reaction disappearedThe reaction was reducedNo change in the reaction








YesNo




ABOUT PRODUCT

Suspect Drug:













YesNo

YesNo

YesNo




YesNoDoesn’t Apply


YesNoDoesn’t Apply




CONCOMITANT DRUGS:

(do not mention treatment of the event):

Brand Name

Generic name

Date Person Started Drug

Date Person Stop Drug




ABOUT REPORTER:














FORM MK - 03-01