Report an adverse reaction

Ru Eng

Adverse event report form

Report*

Initial Secondary

Patient's information

Applicant information:*

Not Healthcare Worker Healthcare Worker

Full name*

Date of birth*

Job title*

Organization*

Sex*

Male Female

Height (cm)

Weight (kg)

Treatment

Outpatient Inpatient

Country*

Address*

Telephone

E-mail*

Information about the person who prescribed the treatment

Full name

Address

Telephone

E-mail

Medicinal product suspected of causing AE

Name of the medicinal product*

Indications for this medicinal product administration

Route of administration

Daily dose

Product shelf life

Batch

Medication start date

Medication end date

Manufacturer information

AE presumably associated with the medicinal product administration

Description of the adverse event*

AE onset date

AE end date

AE outcome

Actions taken

Additional information on AE

Any additional information on AE, any performed therapy, studies performed

Concomitant therapy within the last 3 months
(including medicinal products and dietary supplements used for self-medication)

Name of the medicinal product

Route of administration

Therapy start date

Therapy end date

Indications

List comorbidities

Social habits

Allergic reactions to medication

I am aware of the rules for the personal data processing