Adverse Drug Reaction
Adverse Drug Reaction (ADR) is any response to a drug which is noxious, unintended, and which occurs at doses normally used in man for preventive treatment, diagnosis or therapy of disease or for the modification of physiological function.

People vary in their individual responses to medications. Pre-approval testing with a limited number of subjects does not reveal all possible adverse side-effects of the medication being researched. Only when the new medication hits the market and millions of people use it, ADR becomes apparent.

If you suspect an adverse drug-related event, particularly if unusual, report it to us.

A. Patient Information
1. Name of patient:
2. Age at time of event:
3. Sex:	Male Female
4. Weight:	kgs.
5. Other relevant history, including pre-existing medical conditions (e.g., allergies, pregnancy, smoking and alcohol use, hepatic/renal dysfunction, etc.)
B. Adverse event or product problem
1. Adverse event and/or product problem (e.g. Defects/malfunctions):
2. Outcome attributed to adverse event (tick all that apply):	death If any allergy life-threatening Did he/she require further medical treatment hospitalisation - Immediate/prolonged disability Other:
3. Date of event:	1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1 2 3 4 5 6 7 8 9 10 11 12 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004
4. Date of this report:	1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1 2 3 4 5 6 7 8 9 10 11 12 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004
C. Suspect medication (s)
1. Name (give labelled strength & mfr/label, if known):	1 2 Please send sample/label of suspect medicine
2. Dose frequency:	1 2
3.Therapy dates (if unknown, route used give duration) from/to (or best estimate):	1 2
4. (a) Diagnosis:	1 2
(b) Doctors reference doses:	Yes No doesn’t apply
5.(a) Event occurred after first (indication) dose:	Yes No doesn’t apply
(b) Event occurred after many:	Yes No doesn’t apply
6. Batch/lot (if known):	1 2
7. Exp. date (if known):	1 2
8. Event eliminated after use stopped or dose reduced:	Yes No doesn’t apply
9. Event reappeared after reintroduction:	Yes No doesn’t apply
10. Other medicines given along with the above drug:
Your information:
Name:
Address:
PINcode:
Tel: (O)	(R)
Fax:
E-mail:
Membership No. (If any):
Health Professional?:	Yes No
Your Occupation:
Describe event or problem:
Also reported to:	Doctor Manufacturer Any other:
Has doctor given any advice?:
If you do not want your identity to be disclosed to the manufacturer, please tick this box
Consumer Education and Research Society Tel.: 27489945-46 Fax: 27489947 Email: cerc@cercindia.org