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    Suspected Adverse Reactions Form 0

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    This document is a form for reporting suspected adverse drug reactions to the Bureau of Food and Drugs in the Philippines. It collects information about the patient, suspected drugs, adverse reaction details, management of the reaction, and reporter details. The form requests the patient's name, age, contact information, suspected drugs, dose and frequency taken, date reaction started, treatment given if any, and information about the reporter filling out the form.

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    Suspected Adverse Reactions Form 0

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    127 views1 page
    This document is a form for reporting suspected adverse drug reactions to the Bureau of Food and Drugs in the Philippines. It collects information about the patient, suspected drugs, adverse reaction details, management of the reaction, and reporter details. The form requests the patient's name, age, contact information, suspected drugs, dose and frequency taken, date reaction started, treatment given if any, and information about the reporter filling out the form.

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    This document is a form for reporting suspected adverse drug reactions to the Bureau of Food and Drugs in the Philippines. It collects information about the patient, suspected drugs, adverse reaction details, management of the reaction, and reporter details. The form requests the patient's name, age, contact information, suspected drugs, dose and frequency taken, date reaction started, treatment given if any, and information about the reporter filling out the form.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    127 views1 page

    Suspected Adverse Reactions Form 0

    Uploaded by

    mark
    This document is a form for reporting suspected adverse drug reactions to the Bureau of Food and Drugs in the Philippines. It collects information about the patient, suspected drugs, adverse reaction details, management of the reaction, and reporter details. The form requests the patient's name, age, contact information, suspected drugs, dose and frequency taken, date reaction started, treatment given if any, and information about the reporter filling out the form.

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    of 1

    SUSPECTED ADVERSE REACTIONS FORM For BFAD use only All reports are confidential.

    Saving Lives Through Vigilant Reporting AER No. _________________________


    Date received: _____________________
    Patient Particulars
    Patient's Surname_ __________________________________________________________________________________________
    First Name __________________________________________________________________________________________________
    Age _________ Date of Birth (mm/dd/yyyy) ___________________ Sex:  Male  Female Weight _________Kg

    Contact Number________________________________ Ethnic group:  Filipino  Chinese  Amerasian


     Other (please specify) : ________________________
    Details of the Adverse Reaction
    Outcome:
    Date of onset: ______________________  Recovered (Date of recovery):___________________  Unrecovered
    mm/dd/yyyy
     Fatal (Date of death):______________________  Unknown
    Sequela/e (any permanent complications or injuries as a result of the ADR):
    Time:_________AM ___________PM
     Yes (Please specify)_________________________  No  Unknown

    Describe the reaction/s:________________________________________________________________________________________________


    ____________________________________________________________________________________________________________________
    ____________________________________________________________________________________________________________________
    ____________________________________________________________________________________________________________________
    Suspected drug product(s) Dose Frequency Route Date Date Reason (s) for Manufacturer:
    Indicate brand name started stopped using the product Include: Batch/Lot
    #
                 
         
                  
       
                 
         
                 
          

    List all other drug/s taken at the same time and/ or 3 months before No Other drug/s taken

    Brand name of the drug Dose Frequency Route Date Date Reason/s for using Manufacturer/Batc
    started stopped the drug h & Lot No.

    MANAGEMENT OF ADVERSE REACTION


    Hospitalization (following the ADR):  Yes  No  Already hospitalized before ADR occurred
    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 apply):
     Patient died due to reaction  Involved or prolonged in-patient hospitalization
     Life threatening  Involved persistent or significant disability or incapacity
     Congenital anomaly  Other outcome, please give details: _____________________________________
    Treatment given:  Yes  No (If yes, please specify): ________________________________________________________________
    REPORTER’S PARTICULARS

    Printed Name of Reporter: Contact no:_________________________________________


    Email address: ______________________________________
    Signature of reporter:
    Profession: __MD ___ RPh ___RN___ Patient ____Others
    Date reported (dd/mm/yr):

    Send completed form to: The ADR Unit, BFAD, Civic Drive, Filinvest Estate, Alabang, Muntinlupa 1781. Or fax to: (02) 807-85-11, c/o The
    ADR Unit. Remaining sample of the drug can be sent to BFAD for analysis.

    National Pharmacovigilance Center


    “Saving lives through Vigilant Reporting”
    Bureau of Food and Drugs
    Civic Drive, Filinvest Corporate City, Alabang, Muntinlupa City
    www. bfad.gov.ph

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