PLEASE COPY AND PASTE THE BELOW GUIDELINE AND USE TO FILL OUT THE COMMENTS SECTION:

ADVERSE DRUG REACTION DETAILS :

PERSONAL DETAILS  

– Age, Sex, Weight, Race, Area

DATE OF EVENT            

– Date occurred, Date detected

LOCATION OF EVENT     

– Place occurred (Home / Hospital / Clinic / Nursing Home / Other)

SUSPECTED MEDICINE

– Trade Name, Active Ingredient, Manufacturer

– Strength, Form, Batch no

– Dosage, Frequency, Route

– Prescribed for, Date started, Date stopped

ADVERSE DRUG REACTION

– Details of side effect, Date started, Date stopped

OTHER MEDICINES USED (Including herbal and over the counter)

– Trade Name, Active Ingredients, Manufacturer

– Dosage, Prescribed for, Date started, Date stopped

ADDITIONAL INFORMATION

– Allergies, Pregnancy, Liver Disease, Kidney Disease, Other illnesses

If you are reporting a side effect as a Patient, please provide full contact details for your Health Care Professional.

PRODUCT FEEDBACK DETAILS :

MEDICINE CONCERNED

– Trade Name, Active Ingredient, Manufacturer

– Strength, Form, Batch no

DATE OF EVENT 

– Date prescribed, Date detected

DETAILS OF DEFECT             

– Describe full details of state of product

SOURCE OF PRODUCT

-Please provide full contact details for your Health Care Professional