Individual Case Safety Report


    Date ICSR No. Patient Name Date of Birth Gender
    Weight Height Race Nationality Health Institution Medical Record No Type of Notification Action Taken

    Seriousness of ADR Tick all applicable

    Outcome of ADR (Tick all applicable)

    Event subsided after stopping (de-challenge)

    Event reappears after reintroducing (re-challenge)

    Specific antagonist used

    Suspected Drug(s)
    Brand Name Dosage Form Strength Batch No. MFG EXP Route Used Dosage Regime Treatment Period
    FromTo Indication Concomitant Medicines Recently Discontinued Medications Work Environment in Which The Error Occurred Previous Allergic History The relationship between the suspected drug and the ADR is

    Reporter Name Profession (Specialty) Address E-mail Phone/Mobile Date Signature



    Office # 408 – Rosayes Building – front of Riyadh Chamber of Commerce and Industry HQ Prince Abdulaziz Ibn Musaid Ibn Jalawi St, Al Murabba, Riyadh


    +966 11 4029595

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