Reporting- non-medical persons

Data about the person who provides the information

You are filling this form as

Name

Address

Phone

Email

Information about the patient

Initials

Age

Gender

Female

Male

Weight (kg)

Height (cm)

Information about the suspected drug

Name of the medicial product

1. Dosage form / dosage unit

2. Pharmaceutical company - holder of the authorization

3. Batch number

4. What is the medicine prescribed/recommended for?

5. Application method

6. When did you start taking the medicine?

7. When was the last time you took the medicine?

Intake is not terminated

8. Additional information about the medicinal product

9. Other medicines you are taking at the time of the side effect

Data about the adverse drug reaction (ADR)

Description of the reaction

1. When did the reaction start and how long did it last?

2. Have any measures been taken to treat the reaction and what?

3. What is the outcome of the reaction?

4. How much did the reaction affect your daily activities?

5. Possible cause of the side effect

6. Please add additional information

7. Details of your doctor

Field marked with an asterisk (*) is required.

Drug Safety