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INFORMATION ABOUT THE REPORTER |
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Name |
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Surname |
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Telephone |
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E-mail |
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Country |
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Professional qualification |
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Health institution |
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Date of filling in the application |
 (MM/DD/YYYY) |
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INFORMATION ABOUT THE PERSON WHO EXPERIENCED THE ADVERSE DRUG REACTION
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Initials |
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Country |
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Date of birth |
(MM/DD/YYYY) |
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Sex/age |
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ADVERSE DRUG REACTION INFORMATION
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Description of adverse drug reaction |
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Date of occurrence |
(MM/DD/YYYY) |
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Outcome of adverse reaction |
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Connection between the adverse reaction and the suspected drug |
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SUSPECTED DRUG INFORMATION
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Trade name |
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INN |
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Pharmaceutical form |
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Strength |
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Name of manufacturer |
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Batch number |
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Daily dose |
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Route of administration |
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Indication for use |
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Therapy dates (from) |
(MM/DD/YYYY) |
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Therapy dates (to) |
(MM/DD/YYYY) |
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Therapy duration |
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Did reaction abate after stopping drug? |
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Did reaction reappear after reintroduction? |
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CONCOMITANT DRUGS AND MEDICAL HISTORY
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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. |
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Indicate if the patient had a previous allergy to medication or other chronic diseases |
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If the patient is a woman, whether pregnant or breastfeed |
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