BDA Pharma

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1. Patient Details:

Patient Initials:

Gender:

Age:

Date of Birth:

2. Health Information:

Reason(s) for taking medicine(s) (Disease/Symptoms):

Medicines Advised by:

3. Details of Person Reporting the adverse effect:

Name of reporter:

Address:

City:

State:

Country:

Contact Number:

Email ID:

4. Details of Medicine Taking/Taken:

Medicine Name	Dosage form	Dose of Medicine	Batch No.	Expiry Date	Start Date	Stop Date

5. Describe the adverse effect (what did you do to manage the adverse effect)/Product complain/Any other expericence with drug:

6. Reaction Details:

What did the adverse effect start:

What did the adverse effect stop:

Adverse effect is still continuing:

Yes No

7. How bad was the adverse effect:

Did not affect daily activities

Affect daily activities

Admitted to hospital

Death

Other

8. Concomitant drug and dates of administration (Exclude those used to treat reaction)

*This reporting is voluntary, has no legal implication and aims to improve patient’s safety. Your active participation is valuable. This information provided in this form will be forwarded to our PV department for follow up. You are requested to cooperate with the PV officials when they contact you for more details. Please do report even if you don’t have all the information.

Adverse Event Reporting Form

Nature of Event

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