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ADVERSE DRUG & VACCINE REACTION FORM
ASK YOUR PHARMACIST
Report adverse reactions related to drugs and vaccines.
OK
1.
Demographics
Patient's Name
Age (years/months)
Wt (kg)
City/Town
State/Province
Country
Reporting Person Name
Contact #
2.
Name of Medication?
3.
Route of Administration?
Intravenous (IV)
Oral
Intramuscular (IM)
Subcutaneous (SC)
Topical
Intrathecal (IT)
Intradermal (ID)
Intraosseous (IO)
4.
Dose of Medication?
5.
Frequency of Medication?
6.
What type of reaction?
7.
Do you think the reaction to be serious?
Yes
No
8.
If yes, please indicate why the reaction is considered to be serious (please tick all that apply):
Patient died due to reaction
Life threatening
Congenital abnormality
Involved or prolonged inpatient hospitalisation
Involved persistent or significant disability or incapacity
9.
Did the patient take any other medicines/vaccines/complementary remedies in the last 3 months prior to the reaction? If yes, please give the following information if known:
Drug/Vaccine (Brand if known)?
Batch?
Route?
Dosage?
Date started?
Date stopped?
Prescribed for?
10.
Please describe the reaction(s) and any treatment given: (Recovered, Recovering, Continuing, other)
Current Progress,
0 of 10 answered