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Adverse Experience Reporting Form
(1) Reporter's Information
Name
Location
Contact Number
Email Id
Occupation
Relationship with patient
(if any)
Patient / Self
Doctor / Healthcare Provider
Family Member / Friend
(2) For any Adverse Event and/or product problem
Adverse Reaction
Product Problem
(3) Product involved
Product Name
Dosage last taken (DD/MM/YYYY)*:
Still on therapy ?
Yes
No
Prescribed Lot No./Batch No. & Expiry date (if available)
Product Source
Prescribed (Yes/No)
Yes
No
(3A) Other medicinal products(if any) excluding treatment of reaction
(Name, Dose, Frequency, Route and therapy dates)
(4) Patient Information
Patient Name
Age
Sex
Male
Female
Pregnant Female
Contact No.
Location
Date of Event Onset
(5) Describe Problem
Date of improvement of problem
(6) Seriousness of Event
Death
Life Threatening
Hospitalization
Disability
Resolved
Outcome
Fatal
Recovering
Recovered
Other
Submit Query
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