ADR Report Form
An ADR is any untoward reaction which is associated with drug therapy and requires treatment with prescription medication, results in or prolongs patient hospitalization, results in permanent or temporary disability, results in patient death or requires reporting to FDA.
Please enter the following information:
Patient Name: Medical Record Number:
Date of Birth (MM/DD/YYYY): or age Patient Location:
Patient Gender Male 
Female		 Service:
Report Date : Date of ADR:
Reporter Initials: Reporter Profession:
Suspected
Drug(s):		 Drug Class:
Manufacturer:(optional) Prior Exposure: Yes No
Dose: Route:
Start Date: Stop Date:
Number
of Doses:
Describe Reaction: Concomitant
Drugs:
Treatment of ADR: Relevant Lab Tests / Medical History:
ADR Outcome:
(check all that apply)		 01 Symptoms resolved or improved
02 Required treatment with Rx drug
03 Resulted in hospitalization
04 Prolonged hospitalization
05 Patient death
06 None of the above, required no therapy
07 Other
Action Taken:
(check all that apply)		 01 Drug discontinued
02 Drug continued
03 Dosage reduced
04 Patient counseled



For further information regarding Formweb
please call 800.467.1907.
Copyright © 2024 Rpharmy, LLC ­ All Rights Reserved