Drug Adverse Reaction Report Form

Reporter profile

MM slash DD slash YYYY
Reporter

1. Patient profile

Gender
Pregnant
Lactating

2. Type of drug side effect observed and therapeutic measures taken

3. Date of onset of drug reaction

MM slash DD slash YYYY

4. How long has the condition lasted?

5. Patient history: (allergies, hereditary diseases, enzyme deficiencies, current diseases, addictions, etc.)

6. History of any past drug side effects for the patient

7. Has the observed side effect decreased after stopping the medication?

Answer

8. Has the condition reappeared after repeated use of the medication?

Answer

9. Finally, a drug side effect

Answer

10. Has a medication complication led to the patient being hospitalized?

Answer

11. Paraclinical drug findings related to the observed complication

The results of relevant paraclinical tests (including: blood test results, types of CT scans, MRI, endoscopy, etc.) should be mentioned if available.

12. Drugs suspected of causing side effects

Note: The meaning of pharmaceutical strength is the amount of active ingredient in the dosage form used. (For example: 50 mg ampoule, 100 mg tablet, etc.)

13. Other medications the patient was taking at the time of the complication

Note: The meaning of pharmaceutical strength is the amount of active ingredient in the dosage form used. (For example: 50 mg ampoule, 100 mg tablet, etc.)

Other related explanations

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KishMedipharm Pharmaceutical Company, the only pharmaceutical company on Kish Island and the leading exporter in Hormozgan Province, offers more than 240 pharmaceutical products to the market.

All rights belong to KishMedipharm Pharmaceutical Group, headed by Aida Jalali.