Report of adverse drug reactions

ASPECTUS PHARMA LLC

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INFORMATION ABOUT THE REPORTER

Name *

First

Last

Phone *

Email *

Country *

Professional qualification *

Health institution *

Date of filling in the application *

INFORMATION ABOUT THE PERSON WHO EXPERIENCED THE ADVERSE DRUG REACTION

Initials *

Country *

Date of birth *

Sex/age *

ADVERSE DRUG REACTION INFORMATION

Description of adverse drug reaction *

Date of occurrence *

Outcome of adverse reaction *

Healing, without consequences
Healing with consequences
Undesirable effect in progress
Death
Endangering life
Unknown

Connection between the adverse reaction and the suspected drug *

Sure
Probable
Possible
Little believable
Cannot be classified

SUSPECTED DRUG INFORMATION

Trade name *

INN *

Pharmaceutical form *

Strength *

Name of manufacturer *

Batch number *

Daily dose *

Route of administration *

Indication for use *

Therapy dates (from) *

Therapy dates (to) *

Therapy duration *

Did reaction abate after stopping drug? *

diseases REPORTER and

Did reaction reappear after reintroduction? *

CONCOMITANT DRUGS AND MEDICAL HISTORY

Please list all other medicines you are taking or have been taking in the last week before the occurrence of the adverse drug reaction, including herbal products, vitamins, contraceptiveс, etc. *

Indicate if the patient had a previous allergy to medication or other chronic diseases *

If the patient is a woman, whether pregnant or breastfeed *

ASPECTUS PHARMA LLC is Macedonian pharmaceutical production company.

Company

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