Patient details

Notifier Details




Event Data

 

Next two questions must be answered if the medication has been discontinued, reduced or reintroduced.

The event improved after discontinuation or decreasing the dose of the product?

The event reappeared after the reintroduction of the product?




Medication Suspicion

Other Medications

Please provide information about the suspected medication, including: medication name, daily dose, frequency and route of administration, indication, start and end dates of use, lot, and whether the medication is being used continuously.




Medical History

Patient had this adverse event with this drug in the previous treatment was interrupted?

Patient had another adverse event with this drug in the previous treatment was interrupted? *

Patient had similar symptoms in the past, independent of any measurement?

Patient already had similar symptoms with other medications? **

Patient ever had any other EA? **



* respond only in cases of suspected drug treatment and had been disrupted
**ef so specified in the historic below

Report present and past illnesses, historical poisoning, allergies and other factors and predisposition. (Including relevant Family History).



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