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Pharmacovigilance
Adverse events
Form about an undesirable phenomenon
1
/6
Patient Information
*
— required fields
Message
*
Primary
Secondary
Full name
*
Age
*
Weight (kg)
Height (cm)
Gender
*
Male
Female
Residential address
Phone number
E-mail
*
Treatment
Outpatient
Stationary
Self-medication
Continue
2
/6
Information about the prescribers of treatment
Name of the medical institution
Full name
Address of the institution
Phone number
E-mail
*
— required fields
Skip step
Continue
3
/6
The drug that allegedly caused the undesirable phenomenon
Name of the drug
*
Indications for appointment
*
The way of introduction
Daily dose
Drug series
Start/End date of admission
*
*
— required fields
Continue
4
/6
An undesirable phenomenon, presumably associated with taking the drug
List the symptoms
*
Start date of the phenomenon
*
End date of the phenomenon
*
The outcome of an undesirable phenomenon
Select from the list
Full recovery
Incomplete recovery
Recovery with a complication
Without improvement
*
— required fields
Continue
5
/6
Concomitant therapy for the last 3 months
Including medications and dietary supplements that you take yourself
Name of the drug
Introduction path
Start/End date of admission
*
Indications for appointment
*
— required fields
Skip step
Continue
6
/6
List the concomitant diseases
List the concomitant diseases
Allergic reactions to medication
Consent to
processing of personal data
