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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 e. Fatal
Date of death
or prolonged
Other drugs being taken when reaction occurred : Sl.no.
Name of drug
Daily dose
Route
Date started
Date stopped
Indication Remarks
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 :
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 e. Fatal
Date of death
or prolonged
Other drugs being taken when reaction occurred : Sl.no.
Name of drug
Daily dose
Route
Date started
Date stopped
Indication Remarks
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 :
