1
PATIENT’S DETAILS
Full Name or Initials:
Patient Record No:
Age/Date of Birth:
Sex:
*
M: F:
Weight(kg):
Hospital/Treatment Centre:
2
ADVERSE DRUG REACTION (ADR)
DESCRIPTION
DATE Reaction Started
DATE Reaction Stopped
OUTCOME OF REACTION
TICK AS APPROPRIATE
Congenital Abnormally Life-threatening
Recovered fully Recovered with disability
Death Others (specify)
Was the patient Admitted Due to ADR
Yes No
If already Hospitalized, was it prolonged due to ADR
Yes No
Duration of Admission (days):
Treatment of Reaction:
3
SUSPECTED SWIPHA DRUG
(Including Biologicals Medicines & Nutraceuticals)
DRUG DETAILS
(State name and other details if available / Attach product label / Sample (if available)
Brand Name:
Generic Name:
Batch No:
NAFDAC No:
Expiry Date:
Name & Address of Manufacturer:
Indications for Use
Dosage
Route of Administration
Date Started
Date Stopped
4
CONCOMITANT MEDICINES
(All medicines taken within the last 3 months including Nutraceutical and self-medication)
Brand/Generic
Dosage
Route
Date Started
Date Stopped
Reason for Use
5
SOURCE OF REPORT:
Name of Reporter:
Address:
Profession:
Telephone:
Email Address:

NAVIGATION

 

SOCIAL MEDIA

CONTACT

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+234 811 669 1559

swipha@swiphanigeria.com
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