ADR Report – pharmaadvance.in

Patient Information *

Patient identity is held in strict confidence — no full name required

1. Patient Initials *

2. Age or Date of Birth *

3. Gender *

M F Other

4. Weight (in Kg.)

Reg. No. / IPD No. / OPD No. / CR No.

Suspected Medication(s) *

Up to 4 medications — add rows as needed

S.No.	8. Name (Brand/Generic)	Manufacturer	Batch/Lot No.	Expiry Date	Dose	Route	Frequency	Date Started	Date Stopped	Indication	Causality Assessment
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9. Action taken after reaction & 10. Reaction reappeared after reintroduction

S.No.	Drug withdrawn	Dose increased	Dose reduced	Dose not changed	Not applicable	Unknown	Reappeared: Yes	Reappeared: No	Effect unknown	Dose (if reintroduced)
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ii
iii
iv

11. Concomitant medical products (including self-medication & herbal remedies) — exclude those used to treat the reaction

S.No.	Name (Brand/Generic)	Dose	Route	Frequency (OD, BD, etc.)	Date Started	Date Stopped	Indication
i

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Upload Documents & Investigation Reports

Lab reports · Prescription · ECG · Rash photos · Discharge summary · Any clinical evidence

📷 Rash / Reaction photos 📋 Prescription 🫀 ECG strip 🧪 Lab reports 📄 Discharge summary 🩻 Imaging reports

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Click to browse files or drag & drop here

JPG · PNG · PDF · Max 10 MB per file · Up to 5 files

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Additional Information

Any other relevant clinical information

Reporter Details *

Reporter identity is confidential — submission does not imply legal liability

16. Name & Address *

Pin Code

Contact No.

Occupation / Designation *

17. Date of this report

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Patient identity is held in strict confidence. Submission does not constitute an admission that medical personnel, manufacturer, or product caused the reaction. This form does not replace emergency clinical management. Reports are sent to AMC → NCC-PvPI → WHO Uppsala Monitoring Centre.

Also report directly: pvpi.ipc@gov.in · Helpline: 1800-180-3024

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ADR Report Submitted Successfully

Your report is saved and pending faculty review before PvPI submission.

The Pharmacology Department has been notified by email.
After faculty verification, the report will be forwarded to the PvPI portal (pvpi.gov.in).

Suspected Adverse Drug Reaction Reporting Form

ADR Report Submitted Successfully