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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
5. ............................
6. ............................
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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