ADR Web Form


Section 1 : Report Form

Sender Identifier: *
Report Type:
Initial Report Number:
Case Type:

Section 2 : Patient Demographic

Parent Characteristic
Parent Initials: *
Parent Age: *
Parent Age Unit: *
Parent Age Group:
Parent Sex:
Patient Characteristic
Patient Characteristic
Patient Initials: *
Date of Birth:
Patient Age: *
Age Unit: *
Age Group:
Sex: *
Last menstrual period date:
Pregnancy Status:
Gestation Period:
Gestation period unit:
Weight (kg):
(Please do not enter decimal)
Height (cm):
Ethnic: *
Allergy Status:

Section 3 : Relevant Medical History

Relevant Medical History

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Section 4 : Relevant Investigation / Lab Data

Relevant Investigation / Lab Data

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Laboratory Data
Test Type:
Results date:
Test Type Result Date Result

Section 5 : Adverse Drug Reactions

Adverse Drug Reactions Description: *

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Skin Reaction:
Type of cutaneous reaction:
Part of Body Affected
Onset Date Reaction:
End Date Reaction:
Duration of Reaction:
Duration of Reaction Unit:
Treatment of Reaction:

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Time interval between first dose of suspect drug administration and start of reaction/event:
Time interval unit:
Time interval between last dose of suspect drug administration and start of reaction/event:
Time interval unit:
Extent of the reaction:
Outcome of reaction: *
Seriousness Criteria:
In Case of Fatal / Death
Date of Death:
Cause of Death:
Was autopsy done:
Autopsy determined cause of death:

Section 6 : Drug Details

Characterisation: *
Input Method

MAL Number Product Name Active Ingredient Pharmaceutical Form Action
MAL Number:
Product Name:
Active Ingredient: *
Pharmaceutical Form:
Route of Administration:
Pharmacological Group:
Dose: *
Dose Unit: *
Dose Interval / Frequency: *
Dose Interval / Frequency Unit: *
Cumulative Dose (to First Reaction):
Cumulative Dose (to first Reaction) Unit:
Therapy start date:
Therapy stop date:
Indication: *
Actions Taken with suspected drug: *
Reaction subsided after action taken with suspected drug: *
Reaction reappeared after reintroducing suspected drug: *
Relatedness of suspected drug to reaction(s)/event(s): *

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Characterisation Product Name Active Ingredient Dose / Unit Dose Frequency Start Date End Date

Section 7 : Reporter Information

Qualification: *
Primary Source Information
Primary Reporter Qualification:
Primary Reporter Name:
Primary Reporter Designation:
Primary Reporter State:
Primary Reporter Institution Name:
Primary Reporter Department:
Primary Reporter Address:
Name: *
Types of Institution:
Institution Name: *
Contact Number: *
Email: *
Date of Report:
Report Comments

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