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Patient data:
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Patient initials:
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|
Sex
|
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|
Age
|
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Adverse drug reactions (describe briefly):
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|
Duration of adverse drug reaction (ADR)
|
From:
to:
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|
Trade name
|
|
|
Content form
|
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|
Batch number
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Method of administration
|
|
|
Dosage and frequency of administration
|
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Duration of administration
|
From:
to:
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|
Indications
|
|
|
Trade name 1:
|
|
|
Content form
|
|
|
Method of administration
|
|
|
Duration of administration
|
From:
to:
|
|
Indications
|
|
|
Trade name 2:
|
|
|
Content form
|
|
|
Method of administration
|
|
|
Duration of administration
|
From:
to:
|
|
Indications
|
|
|
Trade name 3:
|
|
|
Content form
|
|
|
Method of administration
|
|
|
Duration of administration
|
From:
to:
|
|
Indications
|
|
|
The medicine being reported was:
|
|
|
Has the patient used the medicine before:
|
|
|
ADR has led to:
|
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|
ADR outcome:
|
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Comments (patient history data, allergies, ADR treatment)
|
|
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Connection between the medicine being reported and the adverse reaction:
|
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Additional information that could not be fitted into the boxes provided
|
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Name:
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Specialty:
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Address:
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Telephone
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|
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