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Information about the person who experienced adverse reactions

Please write Name and Surname or Initials.

Description of adverse reaction

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.

Date, eq.  2014-04-29

Product, which may cause the adverse reaction

eq. 250 mg 2 per day

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

Other, simultaneously taken drugs

Information about main doctor

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

Confirmation of form

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The size of the letter does not matter.

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