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Notification for Healthcare Professionals

Notification of an adverse reaction (ADR) and/or lack of effectiveness (LE) of a medicinal product (MP) during its medical using.

By submitting the form, you agree to the processing of your personal data.

* ‒ Sections required to be filled.

І. GENERAL INFORMATION

Name, Surname of Patient

Sex

Male

Female

Birthday

Start of ADR/LE

End of ADR

Description of ADR/ LE of MP (including data from laboratory and instrumental researches under ADR)

Consequence of ADR/LE

recovery

recovering

no changes

unknown

recovery with consequences

death, not connected with ADR

death, possibly connected with ADR

death due to ADR

ADR/LE category

death of the patient

danger to life

hospitalization of an outpatient

extension of hospitalization

long-term incapacity for work, disability

congenital malformations

another important medical assessment

none of the above

ІІ. INFORMATION ABOUT THE SUSPECTED MEDICINAL PRODUCT (SMP)

Name of the medicinal product (trade name, dosage form)

Manufacturer, country

Series number

Diagnosis

Single dose

Multiplicity of reception

Method of introduction

Start of SMP therapy

End of SMP therapy

ІІІ. INFORMATION REGARDING ACCOMPANYING MEDICINAL PRODUCT
(with the exception of medical products that were used to correct the effects of ADR)

Accompanying medicines

Indication

Single dose

Multiplicity of reception

Method of introduction

Start of therapy

End of therapy

Other important information (diagnoses, allergies, pregnancy with duration, etc.)

IV. RECIPE OF CORRECTION ADR

Cancellation of SMP. Was the cancellation of SMP accompanied by the disappearance of PR?

Yes

Reassignment of SMP. Is the restoration of ADR observed after re-appointment of SMP?

Yes

Changes in SMP dosage (decrease/increase, specify by how much)

Changing the dosage of SMP. Has the renewal of ADR/LE been noticed after changing the dosing regimen of SMP?

Yes

Did perform ADR correction?

Yes

If did, point medicine therapy of ADR/LE (indicate medicine, dosage regimen, term of appointment)

V. INFORMATION ABOUT THE PROVIDER OF THE INFORMATION

Name, surname

Tel.

E-mail

Name and location of health care facility or applicant

Message provided by

doctor

provisory

pharmacist

nurse

other