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Adverse drug reaction reporting form
For VOLUNTARY reporting of Adverse Drug reactions by a ROS member. Please fill a separate form for each patient
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* Indicates required question
Email
*
Your email
email id of reporting member of ROS
*
Your answer
Name of the Institute / City
*
Your answer
Number of patients with the adverse reaction being reported
*
1
2
3
More than 3
Drug name
*
Your answer
Company name
*
Your answer
Batch number
*
Your answer
Name of the procedure
*
Your answer
Date of the procedure
*
MM
/
DD
/
YYYY
Date of presentation with the adverse reaction
*
MM
/
DD
/
YYYY
Any co-morbidities noted in the patient
*
Ocular
Systemic
None
Brief description of the adverse reaction
*
Your answer
Vision before adverse reaction
*
Your answer
Vision at last follow up
*
Your answer
Culture report
*
Negative
Positive
Sampling not done
Management done
*
Topical medications
Oral medications
Intravenous
Surgical
A copy of your responses will be emailed to the address you provided.
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