Form for reporting of adverse drug reactions

Through this form you can send a message to suspected adverse drug reactions seen in the use of medicine to Adipharm EAD. Messages can send all the medical professionals: doctors, dentists, pharmacists, MA and others. Patients who feel that they have appeared side effects of their prescribed medicines, they can report it by appropriate medical specialist. Do not give up on sending the message if there is missing part of the information necessary for completing this form. Reports of drug reaction report to the 24 hours of receipt of: Tel: +359 2 860 2018 E-mail:: phvd.adipharm@gmail.com

Patient(Initials):

Age:

Gender      M   F

Adverse drug reactions(ADR) a brief description	Duration
	From	To

Suspected Drug				Duration of Application
Commercial name		Daily dose	Way of introduction	From	To	Indications

other drugs				Duration of Application
Commercial name	Pharmaceutical form	Daily dose	Way of introduction	From	To	Indications

Suspected drug was:   suspended   reduced dose Is the patient using this medicine before?   yes   no   unknown	ADR led to:   hospitalization   prolongation of hospitalization   life-threatening conditions   congenital anomalies   significant disabilities	Exit of ADR:   Healed without sequelae   recovered with sequelae   treatment continues   unknown   died-date
Comments(history data, allergies, treatment of ADR):		hypersensitivity   drugs   pregnancy   smoking   alcohol

Relationship between suspended drug and ADR:
secure   possible   probable   incredible   conditional   un-qualified	Additional information (If the fields are not sufficient):
Name of sender:

Proffesion:	Address:
Phone:	Date:
Confidential!