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Report Side Effects
Report side effects
ADVERSE REACTION REPORT
ADVERSE REACTION DESCRIPTION:*
DATE OF SUSPECTED ADVERSE REACTION OCCURRENCE:*
1 / Information about the person suspected of having an adverse reaction
FULL NAME:*
GENDER
MAN
WOMAN
YEAR OF BIRTH/AGE:*
TELEPHONE:*
E-MAIL:*
ADDRESS:*
ADITIONAL HEALTH INFORMATION (Chronic diseases, allergy, pregnancy..):
2 / Information about the medicinal product suspected of causing the adverse reaction
NAME OF MEDICINAL PRODUCT:*
USED FROM:
USED TO:
DAILY DOSAGE:
BATCH NUMBER:
USE OF ANY OTHER MEDICATION:
3 / Information about the course of adverse drug reaction
DID REACTION SUBSIDE AFTER DRUG WITHDRAWAL:
YES
NO
DID REACTION APPEARED AGAIN AFTER RE-USE:
YES
NO
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