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Adverse Drug Reactions (ADR) Online Reporting

 

Section (A): Patient Information

Patient initials or ref. no. (Please read instruction 5 below):
Sex: M F: Pregnant? No Yes Unknown
Weight (if known): kg
Date of birth: / / (dd/mm/yyyy) or age (at last birthday):
Ethnic group: Chinese Asian African Caucasian Eurasian Unknown
Others
 

Section (B): About the Adverse Drug Reaction

Date of onset of ADR: / / (dd/mm/yyyy)
Description:
ADR category (for vaccine related ADR only):
Allergic reaction Local reaction Systemic reaction Neurological disorders
Severity (can tick more than 1 box if appropriate):
Life threatening Prolonged Hospitalization
Hospitalised on: / / (dd/mm/yyyy) Hospitalisation NOT required
Laboratory result (if applicable):
All Drug Therapies/Vaccines
Prior to ADR

(Please use trade names and,
for vaccine, indicate batch
number. Please mark the
suspected drug with
asterisk*.)
Daily
Dosage

(dose
number for
vaccines e.g.
1st DTP)
Route Date
Begun
Date
Stopped
Reason for Use
 

Section (C): Treatment & Outcome

Treatment of ADR: No
Yes. Details (including dosage, frequency, route, duration):
Laboratory result (if applicable):

Outcome: Recovered on: / / (dd/mm/yyyy)
Not yet recovered Unknown
Died on: / / (dd/mm/yyyy)
Sequelae: No
Yes: Persistent disability Birth defect Medically significant events
Details:
Allergies or other relevant history (including medical history, liver / kidney problems, smoking, alcohol use etc):
 
Other Information:
 

Section (D): Reporter Details (Please read instruction 6 below)

Name:
Sector of service: Private Public
Occupation: Doctor Chinese medicine practitioner Dentist Pharmacist Nurse
Others
Correspondence Address:
Tel. no.:
Fax. no.:
Email:
Also report to: Manufacturer Distributor / Importer Others
Date of this report:
 

Please read the following instructions:

  1. Please read the Guidance for Healthcare Professionals (http://www.drugoffice.gov.hk/adr.html); and Guidance for Pharmaceutical Industry (http://www.drugoffice.gov.hk/adr_industry.html) before completing the ADR report form.
  2. ADR can be briefly described as a noxious and unintended response to a pharmaceutical product (i.e. drug or vaccine).
  3. If the ADR of a newborn/child may be related to the mother, please submit a separate report for the mother.
  4. Please provide information to every section.
  5. Full name and any kind of personal identifier of the patient, such as identity card number and hospital admission number, should not be provided on the report form.
  6. Information of individual reporter will be treated in strict confidence. Please read the Statement of Purposes in respect of the collection of your personal data.
  7. As limited space is provided, please use another page for additional information if necessary.
  8. For further enquires, please contact the Undesirable Medical Advertisements and Adverse Drug Reaction Unit of Drug Office of the DH at 2319 2920.
 
(Revised in 12/2019)
 
Please enter the five letters as shown above.
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