Dr. D.Y Patil Pratishthan’s
Dr. D.Y Patil College of Pharmacy Akurdi, Pune – 411044
Department of Pharmacy Practice (Pharm. D.)
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Decode (PvPI)
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Simplified ADR Reporting Form
Institution Name
Course Year
Date
1. Patient Information
Age
Gender
Male
Female
Other
Weight (kg)
Contact Number (optional)
2. Suspected ADR Details
Description of Reaction
Date of Onset
Date of Recovery
Outcome
Recovered
Recovering
Not Recovered
Fatal
Unknown
Seriousness
Yes
No
3. Suspected Medication Information
Drug Name (Brand/Generic)
Manufacturer
Batch Number
Expiry Date
Indication (Reason for Use)
Dosage Form & Strength
Route of Administration
Oral
IV
IM
Other
Start Date
Stop Date
4. Concomitant Medications
5. Patient Medical History
6. Reporter Details
Name
Qualification
Institution
Contact Information
Submit
