Adverse Event Form

Adverse Event (AE): any untoward medical occurrence that may present during treatment with a medicine but which does not necessarily have a causal relationship with this treatment.

Adverse Drug Reaction (ADR): a response to a medicine which is noxious & unintended, including lack of efficacy and which occurs at any dosage & can also result from overdose, misuse or abuse of a medicine.

Leave this field blank

Patient Information

Name (or initials):

Weight (kg):

Age:

Height (cm):

Date of birth (dd/mm/yyyy):

Contact Details:

Sex

Male

Female

Adverse Reaction

Date of onset of reaction (dd/mm/yyyy):

Time of onset of reaction:

Description of reaction or problem (include relevant tests/lab data, including dates):

Must be between 1 and 1000 words. Total word count: 0

Medicines

Trade Name & Strength (Suspect Product):

Date Started (dd/mm/yyyy):

Batch No.:

Date Stopped (dd/mm/yyyy):

Daily Dosage:

Reason For Use:

Route:

Other medicine used (include complementary & OTC products used as well):

Adverse Reaction Outcome

Check all that apply:

Was medicine used stopped?

Yes

Comments: (e.g. Relevant history, Allergies, Previous exposure, Baseline test results/lab data)

Forms