ADR Form Page | Genologix

Initials

Surname

Age

Are You Pregnant?

Yes

No

Race

Weight (kg)

Height (cm)

Allergies

Suspected Medicine (Medicine to Have Caused an ADR)

Trade Name (Suspected Medicine 1)

Administration Route

Dosage (mg) & Interval

Date Started

Date Stopped

Reason for Use

Batch Number

Expiry Date

Section Buttons

Suspected Medicine (Medicine to Have Caused an ADR)

Complete Only if You Suspect More than 1 Genologix Medicine is Responsible for Reaction

Trade Name (Suspected Medicine 2)

Administration Route

Dosage (mg) & Interval

Date Started

Date Stopped

Reason for Use

Batch Number

Expiry Date

Section Buttons

Suspected Medicine (Medicine to Have Caused an ADR)

Complete Only if You Suspect More than 1 Genologix Medicine is Responsible for Reaction

Trade Name (Suspected Medicine 3)

Administration Route

Dosage (mg) & Interval

Date Started

Date Stopped

Reason for Use

Batch Number

Expiry Date

Section Buttons

Adverse Drug Reaction/Product Quality Problem

Date of Onset

Time of Onset

Date Reaction Resolved

Please Describe Adverse Reaction/Product Quality Problem. Include as much Clinical Information as Possible

Complete Only if You Were Taking Other Medicines at the Time of Reaction

Other Medicine Customer Was Taking at the Time of Reaction (Including Herbal Medicines)

Trade Name (Other Medicine 1)

Administration Route

Dosage (mg) & Interval

Date Started

Date Stopped

Reason for Use

Batch Number

Expiry Date

Section Buttons

Other Medicine Customer Was Taking at the Time of Reaction (Including Herbal Medicines)

Trade Name (Other Medicine 2)

Administration Route

Dosage (mg) & Interval

Date Started

Date Stopped

Reason for Use

Batch Number

Expiry Date

Section Buttons

Other Medicine Customer Was Taking at the Time of Reaction (Including Herbal Medicines)

Trade Name (Other Medicine 3)

Administration Route

Dosage (mg) & Interval

Date Started

Date Stopped

Reason for Use

Batch Number

Expiry Date

Section Buttons

Other Medicine Customer Was Taking at the Time of Reaction (Including Herbal Medicines)

Trade Name (Other Medicine 4)

Administration Route

Dosage (mg) & Interval

Date Started

Date Stopped

Reason for Use

Batch Number

Expiry Date

Section Buttons

Other Medicine Customer Was Taking at the Time of Reaction (Including Herbal Medicines)

Trade Name (Other Medicine 5)

Administration Route

Dosage (mg) & Interval

Date Started

Date Stopped

Reason for Use

Batch Number

Expiry Date

Section Buttons

Other Medicine Customer Was Taking at the Time of Reaction (Including Herbal Medicines)

Trade Name (Other Medicine 6)

Administration Route

Dosage (mg) & Interval

Date Started

Date Stopped

Reason for Use

Batch Number

Expiry Date

Section Buttons

Genologix Adverse Drug Reaction Form

Suspected Medicine (Medicine to Have Caused an ADR)

Suspected Medicine (Medicine to Have Caused an ADR)

Suspected Medicine (Medicine to Have Caused an ADR)

Other Medicine Customer Was Taking at the Time of Reaction (Including Herbal Medicines)

Other Medicine Customer Was Taking at the Time of Reaction (Including Herbal Medicines)

Other Medicine Customer Was Taking at the Time of Reaction (Including Herbal Medicines)

Other Medicine Customer Was Taking at the Time of Reaction (Including Herbal Medicines)

Other Medicine Customer Was Taking at the Time of Reaction (Including Herbal Medicines)

Other Medicine Customer Was Taking at the Time of Reaction (Including Herbal Medicines)

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