RU | UZ

ADVERSE DRUG REACTION REPORT ON PHARMACEUTICAL PRODUCT

All provided information is confidential and non-disclosure with the exception of the cases stipulated by law

Information about reporter (person who informed about the ADR)

First and Last Name:*

Professional belonging:

Place of work:

Address:

Phone:* E-mail:

Date of receipt of information:*

Information about consumer (patient)

Initials: Gender:*

Age: Age type:*

Liver disease: Kidney disease: Weight (kg):

Pregnancy (term, weeks): Срок недель

Allergy (specify the allergen):

Additional information:

Suspected pharmaceutical product (SPP)

Brand name, medicine form:*

Batch No.: Route of administration:

Prescribed for:*

Dosage:* Frequency:*

Date of start:* Date of stop:*

Other drugs

Other drug
(Brand name, medicine form)		 Dosage Frequency Route of administration Treatment date (from/to)

Adverse drug reaction (ADR)

Description of the ADR:*


Date of start:* Date of stop:* ADR continue

Action taken to treat the ADR:*
none | drug withdrawal | dose reducing |
Co-treatment cessation
medicinal therapy | on-medicinal therapy (including surgical intervention)
other (indicate):

Did the ADR disappear after the suspected drug was stopped?*

Did the ADR reappear after the suspected drug was reintroduced?

Medicinal treatment of ADR:*

ADR outcome:*

Criteria of seriousness:* death | | life threatening
hospitalization – Initial or prolonged
disability
congenital malformation
important medical event (indicate):
none

The module for the employee of the foreign enterprise 'Baraka Dori Farm' LLC

Employee first and last name: Position:

Region: Date of receipt of information:


Видеоинструкция по заполнению формы сообщения о случае побочной реакции Download form



Задавайте вопросы по электронной почте
info@kusum-healthcare.uz

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