DEPARTMENT OF PHARMACOLOGY

SRI SIDHARTHA MEDICAL COLLEGE, TUMKUR

REPORT ON SUSPECTED ADVERSE DRUG REACTIONS

Patient details : initials/ref no. Age Sex:M/F

Weight : Hospital no. : IP/OP
Patient’s diagnosis :
SUSPECTED DRUG (brand name/batch no./manufacturer/expiry date)

----------------------------------------------------------------------------------------------
Dose & frequency :
Route & indication :
Date started :
Date stopped :
Description of suspected reaction : ………………………………………………………...
……………………………………………………………………………………………
……………………………………………………………………………………………
……………………………………………………………………………………………
………
Date reaction started :
Date reaction ended :
Relevant tests/lab data with dates :
TRATMENT OF REACTION …………………………………………………………
………………………………….………..…………………………………………………
……………………………………………………………………………………………
……………………………………
a) Did the reaction end after stopping the drug? Yes/No
b) Was the dose reduced? Yes/No
c) Did the reaction reappear after introduction of the drug? Yes/No not introduced
d) Did the patient have previous history of similar reaction to the same drug or class?
Yes/No
e) Was this a preventable reaction? Yes/No
Please encircle 1. known drug-drug interaction
2 .patient allergic history to medication
3. medication error
OUT COME OF REACTION
a. Recovered Date of recovery
b. Not yet recovered
c. Unknown
d. Hospitalization : initial or prolonged
e. Fatal Date of death
Other drugs being taken when reaction occurred :
Sl.no. Name of drug Daily Route Date Date Indication Remarks
dose started stopped

Relevant additional information including medical history, known allergies, suspected

drug interactions, alcohol use, smoking, hepatorenal dysfunction, pregnancy, drugs taken
in the last 3 months including self medication.

Reporting Doctor/pharmacist
Name, address & phone no.:
Signature with date :