Adverse events

Form about an undesirable phenomenon

1/6Patient Information
* — required fields
Gender*
Treatment
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2/6Information about the prescribers of treatment
* — required fields
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3/6
The drug that allegedly caused the undesirable phenomenon
Start/End date of admission*
* — required fields
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4/6
An undesirable phenomenon, presumably associated with taking the drug
* — required fields
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5/6Concomitant therapy for the last 3 months

Including medications and dietary supplements that you take yourself

Start/End date of admission*
* — required fields
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6/6List the concomitant diseases
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