Drug Safety Patient Information Patient Name Patient Age Patient Gender MaleFemale Patient Phone Describe what happenedDescribe what happened in your own words, any symptoms or side affects you suspect were caused by your medicine, and what happened since then.Other specific details about each medicine and relevant dates can be entered below, but please include enough information here to connect to the Reactions/Symptoms section below Description Reactions/SymptomsDescribe the reactions in your own words. Click the 'Add another reaction/symptom' button for each reaction you will describe. Reactions Start Date End Date Duration Outcome of reaction Recovered/resolvedRecovring/resolvingNot recovered/ not solvedRecovered with some lasting effectsFatalUnknown Did the reaction lead to any of the following? DeathLife threateningDisabling/incapacitatingCaused/prolonged hospitalisationCongenital anomaly/birth defect Medicine name Reason for giving the medicine Why did you prescribe the medicine? (For example: Diabetes, headache) Additional informationPlease give a short description of your medical history. This is important since some reactions only appear with a combination of previous or ongoing disease, special diets, recreational drugs, smoking habits, alcohol intake or allergies. You can also enter other comments you feel are important. Current and previous illnesses Additional comments Reporter Contact details
