LalliCareClinic.ca

1139 Yates St - Victoria , BC V8V 3N2 - PHONE: 250-386-5100 - Fax: 250-386-5527 - TOLL FREE: 1-866-261-4165

Report an Adverse Drug Reaction

To report an adverse drug reaction please fill out the form below, scroll to the bottom of the page and click "Submit"

A. Patient Information
1. Patient identifier 2. Age at time of     reaction 3. Sex 4. Height 5. Weight
male feet lbs
Chart Number Date of birth or or
female cm kgs
B. Adverse Reaction
1. Outcome attributed to adverse reaction(check all that apply)
Death Disability
Life Threatening Congenital Malformation
Hospitalization Required intervention to prevent
       damage / permanent impairment
Hospitalization-Prolonged Other:
2. Date and time of reaction
    (dd/mm/yyyy)		   3. Date of this report
    (dd/mm/yyyy)
 
4. Describe reaction or problem

5. Revelant tests / laboratory data (including dates (dd/mm/yyyy))

Submission of a report does not constitute an admission that medical personel or the product caused or contributed to the adverse reaction.
C. Suspected drug products(s)
1. Name (give labelled strength & manufacturer, if known).
#1 
#2 
2. Dose, frequency, & route used
 3. Therapy dates(if known, give duration).
     From (dd/mm/yyyy) to (dd/mm/yyyy)
#1  #1 
#2  #2 
4. Indication for use of suspected drug
     product		 5. Reaction abated after use stopped or
     dose reduced.
#1  #1  Yes No Doesn't apply
#2  #2  Yes No Doesn't apply
6. Lot # (if known) 7. Exp. Date (if known)
     (dd/mm/yyyy)		 8. Reaction reappeared after
     reintroduction
#1  #1  #1  Yes No Doesn't apply
#2  #2  #2  Yes No Doesn't apply
9. Concomittant drugs(name, dose, frequency and route used) and therapy dates
     (dd/mm/yyyy)(exclude treatment of reaction)


10. Treatment of adverse reaction
     (drugs and/or therapy), including dates(dd/mm/yyy)

D. Reporter
1. Name, address, email, & phone number.


2. Health
     professional?		 3. Occupation 4. Also reported to
     manufacturer?
Yes No Yes No
E. Suspect Medical Device
1. Brand name
 
2. Type of device
 
3. Manufacturer name & address

4. Operator of device
Health professional Lay user/patient Other    
5. Expiration date
     (dd/mm/yyyy)
 7. If implanted, give date
     (dd/mm/yyyy)		 8. If explanted, give date
     (dd/mm/yyyy)
           
6.
Model #     Serial #      Catalog #  
Lot #         Other        
9. Device available for evaluation? (Do not send)            (dd/mm/yyy)
Yes No returned to manufacturer on
10. Concomitant medical products and therapy dates (exclude treatment of event)
     (dd/mm/yyy)

 
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