Adverse drug reaction form for medical professionals

I. General information

Full name of a patient
Please type name.

Outpatient card number

Date of birth
Please type surname.

Gender:
Invalid Input

Consequences of adverse event/lack of efficacy

Onset of AE/LE (date)
Please type adress.

Onset of AE/LE (time)
Invalid phone number

Outcome of AE (date)

Outcome of AE (time)

Description of AE/Indication of LE of a medicinal product

(including the findings of laboratory and instrumental research related to AR)

Class of AE/LE of a medicinal product

II. Information about suspected medicinal product

Trade name

(trade name, pharmaceutical form)

Manufacturer, country
Please fill the form

Batch number

Indications

(specify the ICD-10 code, if possible)

Single dose

Dosage frequency

Method of administration

Onset of a treatment

Termination of a treatment

III. Concomitant medications

(except for medicines used to correct the consequences of AE)

Concomitant medications

(trade name, pharmaceutical form, manufacturer)

Indications

(specify the ICD-10 code, if possible)

Dosage frequency

Method of administration

Onset of a treatment

Termination of a treatment

Single dose

the second MP

Concomitant medications

(trade name, pharmaceutical form, manufacturer)

Indications

(indicate the ICD-10 code, if possible)

Single dose

Dosage frequency

Method of administration

Onset of a treatment

Termination of a treatment

the third MP

Concomitant medications

(trade name, pharmaceutical form, manufacturer)

Indications

(specify the ICD-10 code, if possible)

Single dose

Dosage frequency

Method of administration

Onset of a treatment

Termination of a treatment

Other important information

(diagnosis, allergy, length of pregnancy, etc.)

IV. MP used to correct AE

Withdrawal of SMP

Did the AE reduce during the SMP withdrawal?

Was the SMP administered again?

Did AE re-appear after restarting SMP?

Change of dosage frequency of SMP

reduced/increased, please specify

Did AE/LE re-appear after changing the dosage frequency of SMP?

There were no actions taken to correct the AE

Drug therapy of AE/LE

(specify the MP, dosage frequency, duration of treatment)

V. Cause-and-effect relationship between clinical manifestations of AE and SMP

VI. Reporter information

Full name
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Phone

Email

Form is submitted by:

Name and location of the health care facility or an applicant
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“We Act to Save Lives”

Mistral Capital Management Limited

“We Act to Save Lives”

Mistral Capital Management Limited