APPLICATION OF ADVERSE REACTION OF MEDICINAL PRODUCT/SUPPLEMENT OF DIET/MEDICAL PRODUCT

Fields containing * are required

Who experienced an adverse reaction?

Information about the person who experienced adverse reactions

Name *

Surname *

Gender *

Please write Name and Surname or Initials.

Age *

Height [cm]

Weight [kg]

Street

Building's number

Apartment number

Post Code

Locality

Voivodeship

Phone *

E-mail *

Vital information

Description of adverse reaction

What adverse reaction did you observe? *

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.

How strong was an adverse reaction? *

When did adverse reaction of medicinal product/supplement of diet/ medical product begin? *

Date, eq. 2014-04-29

Was any treatment of adverse reaction taken?

Do one stop using of medicine because of adverse reaction?

Do symptoms step back after stop using product?

Do one resume use of medicine?

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

Product, which may cause the adverse reaction

Name of medicine *

Producer of medicine

Dosage

eq. 250 mg 2 per day

Prescription

Medicine form

Reason of using the medicine

Date of beginning using of product

End date of using of product

If you use in the same time other medicines/supplements of diet/medical products please give information about that

Other, simultaneously taken drugs

Name of the Drug

Dosage

Reason

Date of beginning using of product

End date of using of product

Name of the Drug

Dosage

Reason

Date of beginning using of product

End date of using of product

Name of the Drug

Dosage

Reason

Date of beginning using of product

End date of using of product

Name of the Drug

Dosage

Reason

Date of beginning using of product

End date of using of product

Name of the Drug

Dosage

Reason

Date of beginning using of product

End date of using of product

Name of the Drug

Dosage

Reason

Date of beginning using of product

End date of using of product

What is your opinion about current health condition?

Information about main doctor

Do you want us to let know main doctor about occurring of adverse reaction?

Name of doctor

Surname of doctor

Please provide the data of therapeutic entity (place/institution where the therapy was ordered)

Street

Building's number

Apartment number

Post Code

Locality

Confirmation of form

Verifying Code *

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﻿APPLICATION OF ADVERSE REACTION OF MEDICINAL PRODUCT/SUPPLEMENT OF DIET/MEDICAL PRODUCT

Other, simultaneously taken drugs

APPLICATION OF ADVERSE REACTION OF MEDICINAL PRODUCT/SUPPLEMENT OF DIET/MEDICAL PRODUCT