Adverse Drug Reaction Reporting Form

Gulf Pharmaceutical Industry

Adverse Drug Reaction Reporting Form

Please fill out your details below. Fields marked with* are compulsory.

Julphar-Gulf Pharmaceutical Industry

Medical Affairs Department

Tel: +971 7 2 461 461

Fax: +971 7 2 462 462

E-mail: medical.affairs@julphar.net

Web: www.julphar.net

PO Box 997 , Ras Al-Khaimah

United Arab Emirates

*1. Date of Event:

(dd/mm/yyyy)

*2. Reporter details

Name:

Phone No:

Address:

Email:

Organization:

Occupation:

Patient information

*Patient Initials:	*Sex:	*Date of birth: (dd/mm/yyyy)
*Weight: kg	*Height: cm	*Country/ethnic:

Adverse Drug Reaction

*Description of event (according to the reaction site and date the reaction started and ended)

*Is the ADR serious:

If yes: reason for seriousness:

Death, date

(dd/mm/yyyy) Life - threatening Hospitalization- initial

Hospitalization - prolonged Disability Congenital abnormality

Other Specify:

*Outcome of the ADR:

Resolved                    Not resolved, ongoing                       Lost to follow-up                     Unknown
Death date     (dd/mm/yyyy)                             Autopsy Planned/done
                                                                                                                        Autopsy report available

Suspected medication (only the first row is required)

Drug name

Generic name

Daily dose and route

Start date (dd/mm/yyyy)

Stop date (dd/mm/yyyy)

Indication

Concomitant medication(s)

Drug name

Generic name

Daily dose and route

Start date (dd/mm/yyyy)

Stop date (dd/mm/yyyy)

Indication

*Action taken to treat ADR:

Medical treatment, (specify):

Drug stopped Drug reduced, (specify): None

*Did the ADR subside after stopping the suspected medication:

Medical history

(e.g. diagnosis, allergies, pregnancy, smoking, alcohol use, hepatic/renal dysfunction etc.)

Condition	Onset (dd/mm/yyyy)	Details	Present (Y/N)

Laboratory data

Name of test	Date (dd/mm/yyyy)	Results

Additional information

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