The Drug Safety Form

Patient Information*

Suspected Drug Information*

Adverse Reaction Information*

( 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 )

Medical History

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

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

Reporter Information