Adverse Event Reporting Form "*" indicates required fields Patient InformationPatient Name or Initial* Age Age GroupChooseElderlyAdultPediatricGender*ChooseMaleFemaleProduct InformationTrade Name/Generic Name & Strength* Indication Dose Route Frequency Duration Date MM slash DD slash YYYY Batch No. Adverse Event InformationAdverse EventEvent Onset Date MM slash DD slash YYYY Event End Date MM slash DD slash YYYY OutcomeChooseRecoveredRecoveringNot RecoveredUnknownFatalRecovered w / sequelaeCausalityChooseRelatedNot RelatedNot ReportedTreatment Medication, Diagnostic & Lab Values (associated with adverse event(s))Action Taken: What happened after adverse reaction?ChooseDrug DiscontinuedDose ReducedDose IncreasedDosage MaintainedUnknownSeriousnessChooseUnknownSeriousNon-SeriousWere any concomitant drugs taken?ChooseYesNoReporter informationReporter information* Profession (Specialty) Address Email Phone / Mobile* Fax Country* Date MM slash DD slash YYYY
