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Drug safety

Adverse drug reactions reporting form for medical professionals

Data about the reporter

Data about the patient

Gender
Female
Male

Suspected drug product

Other drug products

Adverse drug reactions (ADR)

The medicine being reported was
discontinued
reduced in dose
the treatment still continues
unknown
Has the patient used the medicine before ?
yes
no
unknown
ADR has led to
hospitalization
prolongation of hospitalization
life-threatening condition
congenital anomalies
significant/permanent damage
other events requiring intervention
none of the listed
ADR outcome
recovery without health consequences
ADR is treated
ADR is not treated
recovery with health consequences
ongoing treatment
unknown
death
Application in case of
hyperaesthesia
narcotics
pregnancy
smoking
alcoholic
Connection between the medicine being reported and the adverse reaction
established with certainty
probable
possible
not-likely
conditional
unclassifable

Field marked with an asterisk (*) is required.

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