Download Adverse Drug Event Report Form Luitpold Pharmaceuticals is

Adverse Drug Event Report Form
Luitpold Pharmaceuticals is interested in learning more about the adverse reaction you/someone you
know experienced while being treated with one of our products. We are committed to bringing the
highest quality products and service to the healthcare community across the US, Canada and other
global markets.
Please complete the form below.
Name of Person Completing the form
Address:
E-mail Address:
Phone Number:
Please check preference of contact for additional Information from a Luitpold Pharmaceutical
Representative: Letter to address provided: _________
E-mail:________________
Phone call:________________Best time of day to be contacted:___________
Patient’s Initials:
Patient’s Gender:
Patient’s Age at time of event:
Product Used:
Date first received product:
Reason for Use, if known:
Date Stopped using product or continuing to take
product:
How was it given:
Dose:
Lot # on Product Label if known:
Reaction that occurred:
When did it start:
When did the reaction resolve or is it still ongoing:
Did any of the following occur due to the reaction:
Hospitalized or Hospitalization prolonged__________
Disabled (Permanent health problem)_________
Life-Threatening: __________
Death: _______________
Medical History Event
Start Date
Stop Date or ongoing