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Reporting Adverse Drug Reactions (ADRs)

An adverse drug reaction is any unexpected or dangerous reaction to a drug.

Full Name

Gender

Gender

Weight

Date of Birth

Age at time of reaction

Location where the reaction started

If the reaction happened in another country, please state the name of the country

Medicines
(Enter the name and details for all medicines you were taking before the reaction occurred. Please also describe any herbal preparations, recreational drugs or other alternative medicines you were taking.)

Please state the medicines that may have caused the reaction

Medicine producer (Company name on package)

Batch number(s)

Dosage of each medicine
(How much did you take? For example: '2 tablets 50 mg, 3 times a day')

How was the medicine administered

Describe what happened
(Describe what happened in your own words, any symptoms or side effects you suspect were caused by your medicine, and what happened since then.)

Reactions/Symptoms
(Describe all the reactions in your own words.)

Start date

End date

Duration of the reaction

Outcome of the reaction

Is the medication(s) probably causing the reaction?

Is the medication(s) probably causing the reaction?
A
B
C

Is the reaction serious?

Is the reaction serious?
A
B

Reason for taking the medicine
Why did you take the medicine? (For example: Diabetes, Headache)

Action taken with the medicine

Additional information

(Please give a short description of your medical history. This is important since some reactions only appear with a combination of previous or ongoing disease, special diets, recreational drugs, smoking habits, alcohol intake or allergies. You can also enter other comments you feel are important.)
Current and previous illnesses

Additional comments

Location where medicine was bought

If medicines were bought at HealthPlus, please upload receipt or proof of purchase

Email

Phone Number