Use this form as medical professional to report any side effect or ADR of your suspect
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Reporter Information
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# Health facility
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Add Patient Information
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# Other Information
Suspected Reaction
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Add medicine, cosmetic or medical device information
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# Name Batch number Expire date Where you get Dosage How often per day How it was used Date started Reason for use
No Content Added!
Herbal Medicine Information
No Yes
Laboratory Data
# Test Date started Complaint type Creator
No Content Added!
Case Outcome
Reaction subsided after stopping the suspected drug / reducing the dose
No Yes Unknown
Reappeared after reintroducing suspected drug
No Yes Not applicable
Do you consider the reaction to be serious
No Yes
Treatment of adverse reaction / event
No Yes
Outcome:
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