Adverse Drug Reaction (ADR) Report Form
Patient Name:
Patient Age:
Patient Gender:
Select Gender
Male
Female
Other
Drug Name:
Drug Dosage:
Reaction Description:
Reaction Start Date:
Reaction End Date (if applicable):
Reaction Severity:
Select Severity
Mild
Moderate
Severe
Life-threatening
Reporter Name:
Reporter Email:
Reporter Phone:
Submit ADR