Patient Information

Initials or Patient ID Age Sex Female Male Other Weight (kg)

Suspected Drug(s)

Drug Name Manufacturer Batch/Lot Number Dose Route of Administration Start Date Stop Date Indication for Use

Adverse Reaction Details

Description of Reaction Date of Onset Date Reaction Stopped Seriousness Death Life Threatening Hospitalization Disability Other Outcome Recovered Recovering Not Recovered Fatal Unknown

Concomitant / Past Medication

List Medications

Reporter Information

Name Contact Information Profession/Title Date of Report