Drug Safety HPG

The Drug Safety Form

Name*

Age*

Gender*

Phone*

Product Name

Daily dose

Indication for use

Route of Administration

( A description of the adverse reaction it self, such as the signs and symptoms experienced, start date, end date and the result of the reaction )

Report *

Current or past relevant medical history (including concurrent illness, allergy, smoking, alcohol abuse, pregnancy)

Yes If yes, please specify

Report *

Concurrent medication (Medication taken during the past 3 months prior to the event)

Drug Name & Concentration

Dose

Indication

Route of Administration

Start date

End date

Patient

Physician

Pharmacy

Others

Report *

Name

Telephone/Mobile