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.

Patient Information

Patient's Name*

Patient's Age

Patient's Weight

Patient's Height

Patient's Date Of Birth

Patient's Contact Details*

Patient's Gender

Adverse Reaction

Date Of Onset Reaction

Time Of Onset Reaction

Description Of Reaction*

Medicines

Trade Name Batch Number*

Batch Number

Date Started

Date Stopped

Daily Dosage

Reason For Use

Other Medication Used (Include Strength)

Adverse Reaction Outcome

Medication Stopped

Patient Hospitalised

Hospital Stay extended

Other Medication Needed

Other Intervention

Details

Current Status Of Patient

Response Required By Complainant:

Forms