NDL FORM ASSOCIATED WITH EXPOSURE TO FATHER’S DRUG

Data of reporting person

Fields containing * are required

Name *

Surname *

Function

Name of function

Degree

Street

Building's number

Apartment number

Post Code

Locality

Country

Phone *

Email *

Information about father (patient)

Initials of father *

Date of birth

Age

Weight

Height

Data of mother

Initials Of Mother

Age *

Date of birth

Weight

Height

Data of child

Initials of child

Age

Date of birth

Weight

Height

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

Information about pregnancy

The estimated date of conception

Date of birth / expected date of birth

The contraceptive using method (if applicable)

RESULTS OF RESEARCH / TESTS IN LABORATORY

DESCRIPTION IN CONNECTION WITH THE HISTORY OF MEDICAL AND / OR DISEASES OCCURRING IN THE FAMILY OF THE FATHER

DESCRIPTION IN CONNECTION WITH THE HISTORY OF MEDICAL AND / OR DISEASES OCCURRING IN THE FAMILY OF THE MOTHER

RESULT OF PREGNANCY

Childbirth forces of nature?

Childbirth on time?

Birth weight

Gender

Confirmation of form

Verifying Code *

Please write the text from the picture above.

The size of the letter does not matter.

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﻿NDL FORM ASSOCIATED WITH EXPOSURE TO FATHER’S DRUG

Description of adverse reaction

RESULT OF PREGNANCY

NDL FORM ASSOCIATED WITH EXPOSURE TO FATHER’S DRUG