Report an Adverse Reaction
1
Patient

General information

Gender *
kg
cm

Address

Bad habits

Other information

Allergies *
2
Adverse reaction

Please, dscribe the adverse reaction

When these symptoms occurred?

3
Medicinal product

Please, describe the medicinal product suspected for causing this reaction

How the medicinal product was used?

When the drug was used?

Was this medicinal product used previously?

4
Other drugs

Have other medicines been used when this reaction occurred? *

5
Measures

Describe what steps have been taken related to this reaction *

How does the person who has experienced the adverse reaction feel right now? *

6
Contact

Who filled this form? *

Please, fill in your contact information

You agree to be contacted if we need to find out more about this case? *

7
Summary
Patient data
General information
Address
Bad habits
Other information
Description of the adverse reaction
Description #1

Severity

Medicinal product suspected for causing this reaction
Medicinal product description
How the medicinal product was used?
When the medicinal product was used?
Other drugs
Taken actions
Patient current health state
Who filled this form?
Reporter
Contact information
Agree to be contacted
Privacy statement: The personal identification data of the patient and the reporter will be kept in confidentiality. Pharmacovigilance staff will not disclose this data to a request from the public. Sending this report does not directly imply the conclusion that the medical staff, the manufacturer or the medicinal product have determined or contributed to the occurrence of the adverse reaction.
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