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Suspected adverse drug reaction reporting form
For VOLUNTARY reporting of Adverse Drug Reactions by ophthalmologists. Please fill a separate form for each patient.
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* Indicates required question
Patient initials
*
Your answer
Age at time of event
*
Your answer
Gender of the patient
*
Female
Male
Other:
Date of adverse event
*
MM
/
DD
/
YYYY
Name of the centre/institute with City and State
*
Your answer
Name of procedure
*
Your answer
Suspected drug name
*
Your answer
Suspected drug batch number
*
Your answer
Manufacturing company
*
Your answer
Dealer
*
Your answer
Nature of adverse event/effect
*
Eye
Systemic
Both
Other:
Brief description of the adverse effect
*
Your answer
Vision before adverse effect
*
Your answer
Vision after adverse effect
*
Your answer
Vision after resolution of adverse effect
*
Your answer
How was the adverse event managed?
*
Oral medications
Parenteral drugs
Intravitreal injections
Surgery
Other:
Required
Date of resolution of adverse effect
*
MM
/
DD
/
YYYY
Have you reported the adverse effect to
*
Manufacturer
Dealer
Government authority
Other:
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