ADR Form

All information provided is treated in strict confidentiality and will not attract any legal liability.

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Patient Information

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kg
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At least one of the following must be entered: Date of birth, Age at time of reaction
At least one of the following must be entered: Date of birth, Age at time of reaction
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Adverse Event Description

Describe what happened in your own words, any symptoms or side effects 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.

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Reactions/Symptoms

Describe the reactions in your own words. Click the 'Add another reaction/symptom' button for each reaction you will describe.

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At least one of the following must be entered: Date of birth, Age at time of reaction
At least one of the following must be entered: Date of birth, Age at time of reaction
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Medicines

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e.g., '2 tablets 50 mg, 3 times a day'
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e.g., Diabetes, headache
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Reporter Information

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