Medicine/Vaccine side effect report

A. Patient Information

B. Suspected adverse reaction

Event / Reaction start date

Event / Reaction stop date

Medicine List

  • Napa
  • Ecospin 25

C. Suspected medications

Name

Manufacturer (if known)

Batch No. / Lot No.

Expiry date (if known)

Dose

Route

Frequency

Therapy Info

Star date

Stopped date

Indication

Causality Assessment

Action taken after reaction

Reaction reappeared after reintroduction of suspected medication

Concomitant medical product including self-medication and herbal remedies with therapy dates (Exclude those used to treat reaction)

Name

Dose

Route

Frequency (OD, BD, etc.)

Therapy Info

Star date

Stopped date

Indication

FOR AMC / NCC USE ONLY

Red. No. /IPD No. / OPD No. / CR No.

AMC Report No.

Worldwide Unique No.

Seriousness of the reaction

Outcome

D. REPORTER DETAILS

Confidentiality: The patient's identity is held in strict confidence and protected to the fullest extent. Submission of a report does not constitute an admission that medical personnel or manufacturer or the product caused or contributed to the reaction. submission of an ADR report does not have any legal implication on the reporter.