Adverse events

Message^*

Primary Secondary

Full name^*

Age^*

Gender^*

Male Female

Phone number

E-mail^*

Treatment

Outpatient Stationary Self-medication

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2/6Information about the prescribers of treatment

Name of the medical institution

Full name

Address of the institution

Phone number

E-mail

^* — required fields

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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

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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

^* — required fields

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5/6Concomitant 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

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6/6List the concomitant diseases

List the concomitant diseases

Allergic reactions to medication

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The processing of personal data, including information about the health status, is carried out by the Operator in order to comply with the requirements of the legislation on pharmacovigilance in accordance with the Federal Law No. 61-FZ dated 12.04.2010 "On the Circulation of Medicines".

Adverse events

Form about an undesirable phenomenon

1/6Patient Information

2/6Information about the prescribers of treatment

3/6

The drug that allegedly caused the undesirable phenomenon

4/6

An undesirable phenomenon, presumably associated with taking the drug

5/6Concomitant therapy for the last 3 months

6/6List the concomitant diseases

Adverse events

Form about an undesirable phenomenon

1/6Patient Information

2/6Information about the prescribers of treatment

3/6 The drug that allegedly caused the undesirable phenomenon

4/6 An undesirable phenomenon, presumably associated with taking the drug

5/6Concomitant therapy for the last 3 months

6/6List the concomitant diseases

3/6

The drug that allegedly caused the undesirable phenomenon

4/6

An undesirable phenomenon, presumably associated with taking the drug