Suspected adverse drug reaction reporting form
For VOLUNTARY reporting of Adverse Drug Reactions by ophthalmologists. Please fill a separate form for each patient.
Patient initials *
Your answer
Age at time of event *
Your answer
Gender of the patient *
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 *
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? *
Required
Date of resolution of adverse effect *
MM
/
DD
/
YYYY
Have you reported the adverse effect to *
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