ADRS-FORM - Leeford

Name of Drug (Leeford Healthcare Drug only)^*

Nature of Event (Check all that may apply)

Sex:^*

Male

Female

Others

Reaction/Event start Date:

Reaction/Event stop Date:

Description of Reaction/Event
(What and how it has happened):

Reaction/Event Management
(Things done to resolve or manage the Reaction/Event):

Suspected Medication(s) Details
(Medicines used during the therapy when the event or reaction occurred):

Name of Drug (Brand/Generic)-

Route of Administration :

Frequency of Usage:^*

Admitted for the treatment off :

Severity & nature or Reaction/Event :

Casuality Assessment :

Action taken after Reaction/Event (What’s done with all the drugs involved):

Drug Withdrawn

Dose Increased

Dose Decreased

Dose not changed

Not Applicable

Unknown

Reaction/Event reoccurred/reappeared after reintroduction of the suspected medications (about all drugs involved):

Yes-

No-

Effect unknown:

Dose if reintroduced:

Concomitant Medical product (Write about all, what are being used) including self medication & herbal remedies with therapy dates (Exclude those used to treat or manage ADR):

Name :

Dose:

Route:

Frequency :

Duration:

Date started :

Date Stopped:

Indication/s:

Relevant tests/laboratory data with dates:

Relevant medical/medication history

Allergies

Race

Pregnancy

Smoking

Alcohol use

Hepatic/renal dysfunction

None of the above

Seriousness of the reaction

If Yes

Hospitalization (initial or prolonged) :

Congenital anomaly :

Required intervention to prevent permanent impairment/damage :

Recovered with sequel:

FOR AMC / NCC USE ONLY

Date of this Report:^*

Add Prescription Image:^*

ADRS FORM

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