Suspected Drug Adverse Event (Side Effect) Reporting Form for Non-Healthcare Professionals


Patient Details



MaleFemaleOther


NeonateInfantChildAdolescentAdultElderly



YesNo

Description of the Event

Sr. Event Date Started Date Stopped Whether Ongoing
 1.
 2.
 3.
 4.

Present Status

Completely recoveredRecoveringOngoingDeathUnknownOther

Suspected INTAS Drug Details

Sr. Drug Name, Strength, Pharmaceutical Form Brand Name Condition / Symptom for which it was given Details of Dosing Route of Administration
 1.
 2.
History of the Suspected INTAS Drug Given (as listed above)
Sr. Date Started Ongoing? Date Ended Lot No. / Batch No. Expiry Date
 1.
 2.
Other Medication Given with the INTAS Drug, If Known
Sr. Drug Name, Strength, Pharmaceutical Form Brand Name Condition / Symptom for which it was given Details of Dosing Route of Administration
 1.
 2.
 3.
 4.
Additional Relevant Information, If Known

If 'Yes', please specify

Reporter Details