- Drug unwanted reaction reporting form -

test

Details of the person providing the information

Medical specialist?

Yes No

Name:

Work address:

Contact phone:

e-mail:

Patient data

Name, Surname / Initials:

Gender:

Man Woman

Age:

Suspected medicinal product

Medicine:

Dosage form / Dosage unit:

Batch number of the medicinal product:

Daily Dose:

Start of treatment:

End of treatment:

Application method:

Indications / Reason for taking the medicine:

Has the patient used the same medicine before?

Yes No Unknown

Has the suspected drug been discontinued?

Yes No Reduced dose

Have measures been taken to treat the reaction and what?

Yes No Unknown

Description of measures (if any):

Unwanted medicinal reaction

Description of the unwanted reaction:

Start date:

End date:

Does the unwanted reaction disappear when the medicine is stopped being taken?

Yes No Unknown

Does the unwhanted reaction appear when the medicine is taken again?

Yes No Unknown

Does the unwanted reaction lead to:

Admission of the patient to hospital or extension of hospital stay? Life threatening condition? Permanent and significant disability? Hereditary anomaly or birth defect? Is ADR clinically significant, does it require surgery or medical intervention to prevent some of the consequences described above? Has the patient died?

If you agree to seek further information in this case from your doctor, please provide contact details.

Additional information:

I agree with the general terms and the personal data protection rights policy and i accept them

I agree that the sensitive personal data I have provided should be processed for the purpose of reporting adverse reactions.

I agree with the general terms and the personal data protection rights policy and i accept them

0,00 BGN

Categories

Medicines

Immunity

Flu and colds

Mom and baby

Children's health

Women's health and beauty

Antiseptics

Dental health

Nervous system

Cardiovascular system

Digestion and liver

Musculo-skeletal system

Vitamins and minerals

- Drug unwanted reaction reporting form -

Details of the person providing the information

Patient data

Suspected medicinal product

Unwanted medicinal reaction

About us

Products

Blog

Contact us

Information

Secured payments with:

Medicines

- Drug unwanted reaction reporting form -

Details of the person providing the information

Patient data

Suspected medicinal product

Unwanted medicinal reaction

Do you want to receive news and advice from us?

Subscribe to our newsletter and be always informed!