Report an adverse event of the drug by filling out the form on our website

Patient Data

Patient Initials (Patient ID) *

Male

Female

Weight (kg.)

Age

Allergy:

No

Yes

Liver dysfunction:

Yes

No

Unknown

Kidney problems:

Yes

No

Unknown

Drug suspected of causing HP

Drug name (trade) *

Manufacturer

Series number

Dose, route of administration

Start date of therapy

End date of therapy

Indication

Adverse reaction

Description of the reaction * (include all details, including laboratory data)

HP Start Date

Date approved by HP

HP Severity Criteria:

Not applicable
Hospitalization or renewal
Congenital anomalies
Death
Threat to life
Disability
Clinically significant event

Action Taken

No treatment
Reducing the dose of drugs
Medication Therapy
Cancel Suspect PM
Non-drug therapy (including surgery)

Exodus

Not Applicable
Recovery without consequences
Status unchanged
Unknown
Improvement Condition
Recovery with Consequences
Death

Have adverse reactions disappeared / decreased after drug withdrawal?

Yes
No
The drug was not canceled
Not applicable
Unknown

Did the adverse reaction recur after re-administering the drug?

Yes
No
Not applicable
Unknown

Other Drugs You Are Taking

List the drugs taken within the last 3 months, including drugs taken by the patient on their own (voluntarily)

PM №1

Drug name (trade)

Manufacturer

Series number

Dose, route of administration

Start date of therapy

End date of therapy

Indication

Add PM

Reporting Person Data

Qualification *

Doctor

Another Healthcare Professional

Patient

Other

Name

Phone **

Email **

Position

Workplace

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