Drug Adverse Reaction Reporting

Fill the following report

Check All Appropriate To Adverse Reaction
Patient Died
involved or prolonged inpatient hospitalization
Involved Persistence or Sighnificant or Disablitty or Incapacity
Life Threatening
Congenital Anomaly
Other Medically Important Condition

Yes No

Yes No
Therapy Dates

Reporter Details

Pharmacist physician Patient Others
Manufacturer Information

Initial Follow Up