Yellow Card - Submit an Adverse Drug Reaction (CONFIDENTIAL):
Please complete the following information:

(Fields marked with an * are mandatory)


Patients Details:
.
Patients Initials *:
(name, surname)
Age *:
(at time of reaction)
Sex *:
Weight :
(in kg)
Hospital :

Patients Identification number :

(e.g. Patients hospital number or Patients record number)

Sender´s Details:
.
Surname *:
Name *:
Address :
Town :
Postcode :
Telephone *:
Profession *:
Date :
22/09/2017



 Suspect Drugs:

Brand name /
Generic name

Route
of Administration

Dosage

Date
Started

Date
Stopped

Prescribed
for

 Other Drugs:

Brand name /
Generic name

Route
of administration

Dosage
(daily)

Date
Started

Date
Stopped

Prescribed
for


 Suspect Reaction(s):

Reaction
Date
Started
Date
Stopped
Outcome


 Any further details:


 



Do you consider the reaction serious? 

Did the patient die? 

If yes, enter the date of death: 

Did the patient require hospitalisation (prolongation of hospitalisation)? 

Was the reaction life-threatening? 

Was the patient incapacitated or disabled? 

Did a congenital abnormality occur? 

Did you consider the reaction medically significant? 

 Additional Information:

 Please add any further medical history, test results,
 known allergies, rechallenge (if performed), suspected drug interactions.




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