REPORT OF ADVERSE DRUG REACTIONS

REPORT OF ADVERSE DRUG REACTIONS


 
INFORMATION ABOUT THE REPORTER
Name
Surname
Telephone
E-mail
Country
Professional qualification
Health institution
Date of filling in the application Select date in calendar (MM/DD/YYYY)

INFORMATION ABOUT THE PERSON WHO EXPERIENCED THE ADVERSE DRUG REACTION

Initials
Country
Date of birth Select date in calendar (MM/DD/YYYY)
Sex/age

ADVERSE DRUG REACTION INFORMATION

Description of adverse drug reaction
Date of occurrence Select date in calendar (MM/DD/YYYY)
Outcome of adverse reaction




Connection between the adverse reaction and the suspected drug



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) Select date in calendar (MM/DD/YYYY)
Therapy dates (to) Select date in calendar (MM/DD/YYYY)
Therapy duration
Did reaction abate after stopping drug?
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, contraceptive—Ā, 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
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