PharmD Info

ADR Form should have at least four sections which should be completed:

1. Patient information:

- patient identifier
- age at time of event or date of birth
- gender
- weight

2. Adverse event or product problem:

- description of event or problem
- date of event
- date of this report
- relevant tests/laboratory data (if available)
- other relevant patient information/history
- outcomes attributed to adverse event

3. Suspected medication (s):

- name (Generic and brand name)
- dose, frequency & route used
- therapy date
- diagnosis for use
- event abated after use stopped or dose reduced
- batch number
- expiration date
- event reappeared after reintroduction of the treatment
- concomitant medical products and therapy dates

4. Reporter:

- name, address and telephone number
- speciality and occupation

The completed ADR Report Form should be sent to the national or regional ADR centre or to the manufacturer of the suspected product.