ADVERSE DRUG REACTION FORM
Date of ADR:
Hospital Number :
Patient name:
Location
Inpatient Area
Outpatient Clinic
Suspected Drug(s)
Description of suspected ADR:
Intervention Approach:
Physician contacted
Drug Discontinued
Antihistamine, Steroid, Antidote, other given ? If yes, what drug and dose? .
Person reporting ADR and profession
Way to contact: Phone
Beeper
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