Client ADR Reporting Form
Adverse Drug Reaction / Adverse Event Report
For completion by the client/healthcare professional.
This form should not be completed directly by the patient. Please complete all available information and submit, along with supporting documentation where relevant, to pharmacovigilancce@idexis.com.
Client / Reporter Details
Client/Practice Name
*
Contact Person
*
Email Address
*
example@example.com
Telephone Number
*
Please enter a valid phone number.
Format: 000 000 0000.
Preferred contact method
Email
Telephone
WhatsApp
Other
Patient Information
Patient initials/identifier
*
Age/Date of birth
*
Gender
*
Please Select
Male
Female
Other
Prefer not to say
Weight in kg (relevant especially for children)
Relevant medical history
Known allergies
Pregnancy/breastfeeding status, if applicable
Product Details
Product name
*
Strength
Dosage form
Batch number, if available
Expiry date, if available
Date product was supplied
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Prescribed dose and directions
Route of administration
Date treatment started
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Date treatment stopped, if applicable
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Adverse Event / Reaction Details
Date reaction/event started
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Date reaction/event stopped, if applicable
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Description of reaction/event
Was the reaction serious?
Please Select
Yes
No
Treatment required for reaction/event
Outcome of reaction/event
Please Select
Recovered
Recovering
Not recovered
Unknown
Other
Was the product stopped?
Please Select
Yes
No
Unknown
Did symptoms improve after stopping?
Please Select
Yes
No
Unknown
Not applicable
Was the product restarted?
Please Select
Yes
No
Unknown
Did symptoms return after restarting?
Please Select
Yes
No
Unknown
Not applicable
Concomitant Medicines / Supplements
Rows
Medicine / supplement:
Strength:
Dose:
Start date:
Reason for use:
1
2
3
4
5
Additional Information
Other relevant clinical information
Laboratory results, if applicable
Photos or supporting documentation attached?
Please Select
Yes
No
Has the patient received medical attention?
*
Please Select
Yes
No
Unknown
Upload supporting photos or documents
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Additional comments
Client Declaration Details
I confirm that the information provided is accurate to the best of my knowledge and has been obtained from the patient, patient record, prescriber, practice or other relevant source.
Name
*
Designation
*
Signature
*
Date
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Submit
Submit
Should be Empty: