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PELAPORAN EFEK SAMPING OBAT

PENDERITA

Nama : ....................................................................

Usia : ....................................................................

Berat Badan : Kg

Pekerjaan : ....................................................................

Jenis Kelamin : Pria Wanita ( Hamil Tidak hamil Tidak tahu)

Penyakit Utama :

Kesudahan : Semuh

!eninggal

Semuh dengan gejala sisa

Belum semuh

Tidak tahu

Penyakit"K#ndisi $ain yang !enyertai :

%angguan ginjal

%angguan hati

&lergi

K#ndisi media lainnya

'akt#r industri ertanian kimia dan lain*lain

EFEK SAMPING OBAT

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Bentuk"mani+estasi ,.S.- yang terjadi :

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Saat"tanggal mulai terjadi :

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Kesudahan ,.S.-

Tanggal : ..............................................................

Semuh

!eninggal

Semuh dengan gejala sisa

Belum semuh

Tidak tahu

i/ayat ,.S.- yang ernah dialami :

OBAT

Nama dagang"arik BentukSediaan

Beri tanda 0 untuk#at yang di1urigai

Pemerian 2ndikasiPenggunaaan 3ara 4#sis"/aktu Tgl. mula Tgl. akhir

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7. ............................8. ............................9. ............................

. ............................;. ............................. ............................55. ............................

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K,T,&N%&N T&!B&H&N (misalnya ke1eatan timulnya ,.S.- reaksi setelah #at

dihentikan eng#atan yang dierikan untuk mengatasi ,.S.-) :

4&T& $&B-&T-2U! (ila ada)

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Tanggal Pemeriksaan :

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Pela#r

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