APPLICATION OF ADVERSE REACTION OF MEDICINAL PRODUCT

Fields containing * are required

Initials of patient *

Gender *

Number of history of disease

Date of birth

Age *

Weight

Height

Type of application

DRUG SUSPECTED ABOUT ADVERSE REACTION – INFORMATION

SUSPECTED DRUG1

Suspected drug *(trade name, if it is known)

Producer

The serial number of the drug

What adverse reactions did you observe at the patient? *

Start write adverse reactions – form automatically tell if he knows adverse reaction containing the typed string.

When you see the prompt, choose the right one by using the arrows on keyboard and the ENTER key or by clicking the mouse.

When the prompt does not appear, you can approve new adverse reaction by ENTER key – it will be added to list.

If you want to remove any of the listed adverse reaction, click on grey X, which is located on the right side of each adverse reaction.

Please provide additional information about adverse reaction (taken treatment, conducted research etc.)

Information about adverse reaction should be described as precisely as possible, taking into account its severity, duration – and if passed, write if the reaction subsided alone or by the application of treatment. It is relevant to give the reason of using medicine eq. toothache, stomach discomfort, hypertension, conjunctivitis etc. If the reaction did not pass, one should write whether it lowers or increases, whether one applies some ldl treatment, whether the medicine causes permanent consequences to the patient.

The indication for use of the drug

Daily dose/ unit/application frequency

Way of application

Date of first usage of product

Date of last usage of product

Actions taken against the suspect drug

Date of taking action

Description of adverse reaction

Beginning of symptoms (date of occurring adverse reaction) *

End of symptoms (date of end adverse reaction)

The severity of adverse reaction symptom *

Is the adverse reaction passed after withdrawal the drug?

Do the adverse reaction appear again after resume of using the drug?

Result of taking action

Do you think there is a causal link between adverse reaction and suspected drug?

Is this a severe adverse reaction?

Criteria

INTERVIEW – CONCOMITANT DISEASES (during the description please take into account occurring allergies, reactions to other drug etc.)

Other, simultaneously taken drugs

Indication

Daily dose

Way of application

Date of first usage of product

Date of last usage of product

Indication

Daily dose

Way of application

Date of first usage of product

Date of last usage of product

DATA OF REPORTING PERSON

Function

Name *

Surname *

Street

Building's number

Apartment number

Post Code

Locality

Country

Phone *

Email *

Was adverse reaction reported to URPL?

Confirmation of form

Verifying Code *

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﻿APPLICATION OF ADVERSE REACTION OF MEDICINAL PRODUCT

Description of adverse reaction

Other, simultaneously taken drugs

APPLICATION OF ADVERSE REACTION OF MEDICINAL PRODUCT