REPORT ON ADVERSE DRUG REACTION
A. PATIENT INFORMATION
R/N or Initials
:  
Age
:  
Age Group
:  
Sex
:  
Weight
:  
Race
:  
Ethnic Group
:  
       
B. ADVERSE DRUG REACTION DESCRIPTION
ADR Description
: *  
Extent of Reaction
:  
Date of reaction
: CAL (dd/mm/yyyy)  
Date end of reaction
:
(Please leave it blank if not applicable)
 
Time to onset of reaction
: *
Duration of reaction
:  
Type of Report
:  
Outcome of reaction
:
 
Action taken after reaction
:  
Others
:  
Supporting Documents (s)
 
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