Healthcare Professionals – Pokupharma Limited

I. PARTICULARS OF PATIENT

Name of Patient or Record No

Date of Birth (DD-MM- YYYY) or Age:

Gender

Male

Female

Name of Health Facility

Telephone Number:

Weight in Kg

Date Reaction Started

Date Reaction Stopped (if known)

Description of reaction (if possible)

Other relevant information: e.g. medical history, allergies, pregnancy, smoking, alcohol use, etc. Please enclose any relevant laboratory results including dates (if done)

III. DETAILS OF SUSPECTED DRUG(S) AND ALL OTHER DRUGS USED

Name of suspected drug(s)

(Please specify brand name if known)

Batch. No & Expiry date (If known)

Dosage

Route of Administration

Reason for use.

Frequency

Therapy Date Start

Therapy Date Stop

Other drugs

(including complementary drugs, herbal medicines consumed at the same time and or 3months before)

IV. MANAGEMENT OF ADVERSE REACTION.

Reaction subsided after stopping the suspected drug/ reducing the dose:

Yes

No

Reaction reappeared after reintroducing drug:

Yes

No

Not Applicable

Do you consider the reaction to be serious?

Yes

No

If Yes, please indicate why the reaction is considered to be serious (please tick all that may be applicable)

Treatment of Adverse Reaction

Yes

No

If Yes, please specify:

Outcome of the Reaction:

Not yet Recovered

Recovered

Fatal (Date of Death)

V. REPORTER DETAILS:

Name of Reporter:

Name and Address of Institution:

Telephone No:*

Please type the characters*

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Profession:

Date of this report:

Reporter Email address