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Click ‘Get Form’ to open the adverse reaction reporting form in the editor.
Begin with Section A: General Information. Fill in whether this is an initial or follow-up report, and provide the necessary details such as organization name, contact information, and reason for seriousness.
Proceed to Section B: Patient Information. Enter the patient ID, sex, age, height, weight, known medical conditions, and allergies.
In Section C: Serious Adverse Drug Reaction(s), indicate recovery status and provide the start and end dates of the reaction along with a detailed description.
Move to Section D: Suspect Product(s). Input details about up to two suspect products including drug identification number (DIN), brand name, dosage form, and manufacturer information.
Complete Section E: Concomitant Therapeutic Products by listing any other health products taken at the same time as the reaction occurred.
Finally, use Section F for any additional information that may assist in assessing the serious adverse drug reaction.

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2020	4.8 Satisfied (91 Votes)

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adverse reaction form

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