Republic of Botswana - Admin

Department of Clinical Services & Therapeutics
I. PATIENT INFORMATION:
Patient identity
Initials/Reference number:
C O N F I D E N T I A L
ADVERSE DRUG REACTIONS REPORTING FORM
Pharmacovigilance
Age(yrs): Weight (kgs): Occupation:
Sex(M/F):
Reasons for treatment:
Height (cms):
II. ADVERSE EVENT EXPERIENCED/OBSERVED:
Date of onset of Reaction: Discontinuation of Drug/s: Yes No
Description of Adverse Event:
(including laboratory test results)
Nature:
Outcome:
Localized/generalized
Life-threatening
Recovered
Hospitalized (how many days)
Disability
Death(D/M/Y)
unknown
III. SUSPECTED MEDICATION(S)/VACCINE/HERBAL:
Drug Name (use brand name. if
generic name are used please
indicate manufacturer & batch no. if
applicable)
Route Dose Frequency
Date Drug
Started Stopped
D/M/Y D/M/Y
Therapeutic
Indications
Other drugs taken in the last 3 months prior to reaction (including self-medication & herbal remedies)
Reaction Subsided after Suspected
Drug discontinuation
yes No N/A Reaction reappear after
Restart of Suspected Drug
yes No N/A
Treatment for Reaction:
Other Pre- existing medical conditions:
(E.g. Allergies, Race, Pregnancy, Smoking, and Alcohol, Hepatic/Renal Dysfunction, etc ;)
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