Report side effects

ADVERSE REACTION REPORT

ADVERSE REACTION DESCRIPTION:* DATE OF SUSPECTED ADVERSE REACTION OCCURRENCE:*

FULL NAME:*

GENDER

MAN WOMAN

YEAR OF BIRTH/AGE:*

TELEPHONE:* E-MAIL:*

ADDRESS:* ADITIONAL HEALTH INFORMATION (Chronic diseases, allergy, pregnancy..):

NAME OF MEDICINAL PRODUCT:*

USED FROM: USED TO:

DAILY DOSAGE: BATCH NUMBER:

USE OF ANY OTHER MEDICATION:

DID REACTION SUBSIDE AFTER DRUG WITHDRAWAL:

DID REACTION APPEARED AGAIN AFTER RE-USE: