Suspected adverse drug notification

Medical or pharmaceutical worker reporting an adverse reaction

Surname, First name, Patronymic (if any): *

Phone: *

Position and place of work:

Institutional Address:

Treatment:

Message:

Patient Information

Initials:

Medical card number:

Choose gender:

Age:

Weight, kg:

Impaired liver function:

Impaired renal function:

Allergy (indicate what):

SUSPECTED MEDICINE

International Nonproprietary Name:

Tradename: *

Manufacturer:

Batch number:

Indication for use:

Route of administration:

Single dose:

Multiplicity of introduction:

Therapy Start Date:

The end date of therapy:

OTHER SIMULTANEOUS ACCEPTED MEDICINES
(Indicate "no" if the patient has not taken other medicines)

International generic name or trade name of the medicinal product:

Indication for use:

Route of administration:

Single dose:

Multiplicity of introduction:

Therapy Start Date:

The end date of therapy:

Description of the suspected adverse reaction: *

Adverse reaction start date:

Adverse reaction end date:

Suspected drug discontinuation result:

Concomitant diseases, other conditions or risk factors:

Evaluation of a causal relationship:

Exodus:

Action taken:

Other measures taken:

Medicines used to stop an undesirable reaction (if required):

Criteria for categorizing serious adverse reactions (note if appropriate):

Is there a recurrence of an adverse reaction after re-administration of the drug:

Suspected drug is used in:

Important Additional Information

Data from clinical, laboratory, radiological studies and autopsy, including determination of the concentration of drugs in the blood (tissues), if any, and associated with an undesirable reaction (please provide dates):

Concomitant diseases, medical history:

Suspected Drug Interactions:

For congenital anomalies, indicate all other drugs taken during pregnancy, as well as the date of the last menstruation (indicate "no" if such drugs are not available):

Please attach additional pages if necessary.:

date:

Signature (initials of the doctor):

Enter code:*

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