English - Report of adverse drug reactions

INFORMATION ABOUT THE REPORTER

Name

Surname

Telephone

E-mail *

Country *

Professional qualification *

INFORMATION ABOUT THE PERSON WHO EXPERIENCED THE ADVERSE DRUG REACTION

Initials

Country *

Date of birth

Sex/age *

ADVERSE DRUG REACTION INFORMATION

Description of adverse drug reaction *

Date of occurrence *

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/to) *

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 agents, etc.*

Please state possible allergies or chronic health conditions *

If you are a woman, are you pregnant or breastfeeding

*enter code

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