Preskriber | Medical Form

1. Patient's details*

2. Adverse drug reaction(ADR)*

A.

B.

Was patient admitted due to ADR?

Yes

No

If already hospitalized, was it prolonged due to ADR?

Yes

No

C. Outcome of reaction (Tick as appropriate)

Recovered fully

Recovered with disability (Specify)

Congenital Abnormality

Life threatening (Specify)

Death

Others (Specify)

3. Suspected drug (Including biologicals traditional/herbal medicines & cosmetics)*

A. Drug details (State name and other details if available / attach product label / sample (if available))

4. Concomitant medicines (All medicines taken within the last 3 months including herbal and self medication)*

Brand or generic name	Dosage	Route	Date started	Date stopped	Reason for use

5. Upload files/pictures

6. Source of report*

Adverse Drug Reactions (ADRs) Form