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REPORT OF SUSPECTED ADVERSE DRUG REACTION
INCLUDING BIRTH DEFECTS

TANZANIA DRUG AND TOXICOLOGY INFORMATION SERVICES (TADATIS)

(Note: Identities of reporter, patient and institution will remain confidential)

Patient Initials or Record No

Weight

Age / Date of Birth**

Sex** Female Male

(dd/mm/yyyy)

Adverse drug reaction description:**

Date of onset reaction**

All drug therapy prior to reaction or birth. Use brand name(s) if known and tick suspected drug.	Route	Daily Dose	Date Started	Date stopped	Reason for use

Treatment (of reaction):**

Outcome:

Recovered

Not yet recovered

Unknown

Fatal

Died

Dechallenge
(Did the reaction subsided after the drug was stopped or dose reduced?)

Positive

Negative

Not done

Rechallenge:
(Did the reaction reappeared after the drug was introduced?)

Positive

Negative

Not done

Permanent Deformation:

Yes Describe

Comments (e.g relevant history, allergies, previous exposure to this drug):

Reporting Doctor, Pharmacist, etc

Name**

Address

e-mail**

Phone