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For medical or pharmaceutical workers
For medical and pharmaceutical workers
A medical or pharmaceutical worker reporting an undesirable reaction
Full Name
*
Position and place of work
*
Phone number
*
Address of the institution
*
A medical or pharmaceutical worker reporting an undesirable reaction
Initials
*
Sex
*
Select
Male
Female
Weight, kg
Impaired renal function
*
Select
Yes
No
Unknown
Treatment
*
Select
Primary
Repeated
Treatment
Stationary
Outpatient
Self-medication
Medical card number
Age
*
Impaired liver function
*
Select
Yes
No
Unknown
Allergy (indicate that)
Suspected drug
International nonproprietary name
*
Trade name
*
Manufacturer
*
Serial number
Indications for use
*
The route of administration
*
Single dose
*
The multiplicity of the introduction
*
Date of onset of therapy
*
End date of therapy
*
Other concomitant medications
International nonproprietary name
Indications for use
The route of administration
Single dose
The multiplicity of the introduction
Date of onset of therapy
End date of therapy
-
Add
Suspected unwanted reaction
Description of suspected adverse reaction
*
Start date
*
End date
*
The result of stopping the receipt of a suspected drug
*
Select
Explicit improvement
No improvement
Not canceled
Unknown
Not applicable
Concomitant diseases, other conditions or risk factors
*
Evaluation of the cause-effect relationship
*
Select
Credible
Probable
Possible
Doubtful
Conditional
Not classified
Criteria for assessing the cause-effect relationship
The outcome of an undesirable reaction
*
Select
Recovery without consequences
Improvement of the condition
Recovery with consequences
Condition unchanged (not yet recovered)
Death, possibly associated with an undesirable reaction
Exodus unknown
Measures taken
Without treatment
Dose reduction of a suspected drug
Suspension of a suspected drug
Cancellation of concomitant treatment
The use of drug therapy
The use of non-pharmacological therapy (including surgical intervention)
Other (specify)
Drugs used to stop the undesirable reaction (if required)
Criteria for referring to serious adverse reactions
Death
Threat of life
Disability / disability
Hospitalization or its extension
Congenital anomalies
The need for medical intervention to prevent the above conditions
Not applicable
Whether the repetition of the undesired reaction after re-administration of the drug
*
Select
Reactivation of unwanted reaction
No undesired reaction
The absence of an undesirable reaction with a reduced dose
Unknown
No reappointment
Suspected drug is used in
Medical practice
Clinical trials (number of clinical trial protocol)
Important additional information
Clinical, laboratory, radiologic and autopsy data, including the determination of the concentration of drugs in the blood (tissues), if any, and associated with an undesirable reaction (please provide dates)
Associated diseases, anamnestic data
Suspected drug interactions
For congenital anomalies, indicate all other drugs taken during pregnancy, as well as the date of the last menstruation
Form submission date
*
Please attach additional pages if necessary
Fields with
*
is required.
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