Notification of an adverse reaction

Patient Data

Weight (kg)

Age

Gender

MaleFemale

Treatment

OutpatientInpatientSelf-treatment

Allergy

NoYes

Pregnancy

NoYes

Description of Suspected Drug (SD) #1

Therapy Start Date

Therapy End Date

Description of Suspected Drug (SD) #2

Description of Suspected Drug (SD) #3

Adverse Reaction *

Other Drugs Taken in Last 3 Months, Including Drugs Taken by the Patient Independently (Voluntarily)

#3

Therapy Start Date, dd.mm.yy

Therapy End Date, dd.mm.yy

Reporter Information

PhysicianOther Healthcare ProfessionalPatientOther

Contact Phone *

E-mail *

Full Name

Job Position and Workplace

Message Date

Significant Additional Information