ࡱ> ,.+` RObjbjss+D &Jtj"j"j"8"<"l 56V#V#V#V#l#[.2.. e5g5g5g5g5g5g5$47h9>5/+\[.//5V#l#5"000/"V#l#e50/e500Y3J3l#J# jj"0"q31445<5y3,9:09393.0."0./...550...5//// D $ &D  & $.F  Report can be returned by fax to 2572 4570 For follow-up report (see Guidance Notes), please provide ADRMU Ref. No.: _________ Department of Health Adverse Drug Reactions (ADR) Report Form Please read the following instructions: Please read the Guidance Notes for ADR Reporting before completing the ADR report form. This report form is used for voluntary report of all suspected ADR. There is no need to put down the full name of the patient. ADR can be briefly described as a noxious and unintended response to a drug or vaccine when the normal dose is used. Please provide information to every section. Information of individual reporter will be treated in strict confidence. For further enquires, please contact the ADR Monitoring Unit of Pharmaceutical Service of the DH at 2319 8482.  Section (A): Patient Information Patient initials or ref. no.: _______________________ Weight (if known): ____________ kg Sex: M/F* Date of birth: (dd/mm/yyyy) / / or age (at last birthday): _______ For female: Is she pregnant? Yes/No*  Section (B): About the Adverse Drug Reaction Date of onset of ADR: (dd/mm/yyyy) / / Description:______________________________________________________________________________________________________________________________________________________________________ ADR category (for vaccine related ADR only): ( Allergic reaction ( Local reaction ( Systemic reaction ( Neurological disorders Severity: ( Life threatening ( Hospitalised on: (dd/mm/yyyy) / / ( Hospitalisation NOT required All Drug Therapies/Vaccines Prior to ADR (Please use trade names and, for vaccine, indicate batch number. Please circle the suspected drug.)Daily Dosage (dose number for vaccines e.g. 1st DTP) RouteDate BegunDate StoppedReason for Use Section (C): Treatment & Outcome Treatment of ADR : ( No ( Yes. Details: ________________________________________ Outcome:( Recovered ( Not yet recovered (Unknown ( Died on: (dd/mm/yyyy) / / Sequelae: ( No ( Yes: ( Persistent disability ( Birth defect ( Medically significant events Details: ___________________________________________________________________ Remarks (allergies or other relevant history):____________________________________________________ ________________________________________________________________________________________ Section (D): Reporter Details Name of Doctor/Chinese medicine practitioner/Dentist/Pharmacist*: _________________________ in private/public* service. 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