Patient data:

Patient initials:

Sex

MaleFemale

Age

Adverse drug reactions (describe briefly):

Duration of adverse drug reaction (ADR)

From:

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to:

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Trade name

Content form

Batch number

Method of administration

Dosage and frequency of administration

Duration of administration

From:

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to:

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Indications

Trade name 1:

Content form

Method of administration

Duration of administration

From:

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to:

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Indications

Trade name 2:

Content form

Method of administration

Duration of administration

From:

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to:

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Indications

Trade name 3:

Content form

Method of administration

Duration of administration

From:

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to:

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Indications

The medicine being reported was:

DiscontinuedReduced in dose

Has the patient used the medicine before:

YesNoUnknown

ADR has led to:

HospitalizationProlongation of hospitalizationLife-threatening conditionCongenital anomaliesSignificant/ permanent damage

ADR outcome:

Recovery without health consequencesRecovery with health consequencesOngoing treatmentUnknownDeath

Comments (patient history data, allergies, ADR treatment)

Connection between the medicine being reported and the adverse reaction:

Established with certaintyProbablePossibleNot likelyConditionalUnclassifiable

Additional information that could not be fitted into the boxes provided

Name:

Specialty:

Address:

Telephone