SUSPECTED ADVERSE CUTANEOUS DRUG REACTION REPORTING FORM
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Patient's initial *
Age *
Sex *
Required
Name of Suspect Drug *
Brand Name *
Dose Used *
Route Used *
Required
Time interval between drug administration and reaction *
Required
Type of reaction *
Required
Category of Reaction *
A serious adverse event or reaction is any untoward medical occurrence that at any dose results in death, requires inpatient hospitalization or prolongation of existing hospitalization, results in persistent or significant disability/incapacity, is life-threatening.
Required
Severity of Reaction *
Required
Did the reaction resolve after stopping drug? *
Required
Outcomes *
Required
Did the reaction Reappear after restarting? *
Required
In case of Multiple Suspected Drugs please fill in following details
Only drugs that were started recently are to be included
Name of Drug (Dose) (since when)
In case patient is on Multiple concomitant medication fill in following details
Concomitant medications are any drugs which are being given to the patient but are not suspected to be causative agents
Concomitant Medications
Name of drug (dose) (since when)
Doctor's Details
Doctor's Name
Name of the Head of the Department/Hospital
Name of Hospital/Institute
Name of the City
Doctor's email
Doctor's Phone no.
With STD code if applicable
WISH TO FURNISH ADDITIONAL INFORMATION?
Kindly email us at iadvlcadr@gmail.com
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