NDL FORM ASSOCIATED WITH EXPOSURE TO FATHER’S DRUG

Data of reporting person
Fields containing  *  are required

Information about father (patient)
Data of mother
Data of child
DRUG SUSPECTED ABOUT ADVERSE REACTION – INFORMATION
(trade name, if it is known)

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.

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.

Description of adverse reaction

Information about pregnancy

RESULT OF PREGNANCY

Confirmation of form

Please write the text from the picture above.

The size of the letter does not matter.

To change the picture, click on it and wait for a while