Adverse Event Complaint Form Adverse Event Complaint Form We would like to hear from you. Please send us a message by filling out the form below and we will get back with you shortly. Adverse Event Complaint Form* Type of Report Primary Follow Up Name of medical Dept. contact person Date Primary Reporter’s Information Name * Title * Profession * Phone No * Address * Fax * Patient’s Information Initials Height Gender Male Female Weight Age Date of Birth Drug(s) Information Brand Route Dose:(Unit-Freq-Period) Indication Start Date Stop Date Lot Expiry Date Comment Out come and possible relatedness of drug Did the event resulted in one of the following: Death Hospitalisation Disability Life threatening Congenital anomaly Others Possible relatedness of study drug in physicians discretion Yes No Don't Know Final Outcome Final Outcome Fully Recovered Recovering Not yet recovered Recovered with sequel Concomitant Medication(s) Brand Name Daily Dose: Indication Details of Adverse Event“Event Summary Description”: Relevant past history Abnormal Laboratory values Lab. test Result Normal range If you are human, leave this field blank. Submit Δ