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FEEDBACK - HEALTHCARE PROFESSIONAL
Reporter Information
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Patient Details
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Gender:
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Suspected Medication(s)
Name
Brand
Batch No.
Expire Date
Started On
Stopped On
Dose Used
Route Used
Frequency
Indication
Assessment
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About the Side Effect
When did the side effect started?
When did the side effect stopped?
Present Scenario:
recovered
recovering
not recovered
fatal
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Action Taken:
drug withdrawn
dose increased
dose reduced
dose not changed
not applicable
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Seriousness:
Death
congenital anomaly
life threatning
hospitalization
disability
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Describe the side effect:
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