Adverse Drug Reaction (ADR) Reporting Form

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1. ADR Reporting
Form

Pratiksha Thakur

2. Adverse Drug Reachon Reporting Form

Name of Patent 1

Age - SEX + _ Wegnt-_—
Suspeckd drug- o .

Route — Day dose- __ —

Dake Stankd- __ Date Sioppd- ——____—
Todi cahon — _— Suspecked Adummse FLA
Reachon Started Ended | Outcome

| |

Additonal Notes! | Reporting doctor
Name —

Adaress-

Tano-
Stqnothune-

Dare -