The form for reporting adverse drug reactions * required fields 1) PATIENT INFORMATIONPlease provide at least one answer about the patient.Initials Date of birth or age* Body weight (kg)* Height (cm)* Gender*FemaleMale2) CONTACT INFORMATION FOR THE PERSON SUBMITTINGPlease state full name and telephone number or email address of the person submitting the form.First name, last name* Address (street, city/town, country)* Telephone no.*E-mail Qualifications of the person submittingDoctorPharmacistPatientOther medical practitionerNon-PractitionerMedical publication authorReported to drug-control authorities?YesNoUnknown3) INFORMATION ABOUT ADVERSE EFFECTS OF THE MEDICATIONAdverse effects/Diagnosis. If there is no medical diagnosis available, please list all symptoms.*What is the connection between adverse effects and medical product useVery likelyLikelyPossibleUnlikelyNo connectionDate of adverse effects observed Date of adverse effects ending or how long the adverse effects lasted ResultsReturn to healthReturn to health, but with lasting consequencesDuring treatmentDid not regain healthDeathUnknownIs the adverse effect seriousDeathLife-threateningHospitalisationLasting or serious disabilityBirth defect/Foetal damageOther serious medical eventNo connection4) INFORMATION ABOUT MEDICATION(S) SUSPECTED TO HAVE CAUSED ADVERSE EFFECTSName of medication and/or active substance Indication(s) Serial no. Expiry date Dosage, route of administration, pharmaceutical form Start date of administration End date of administration Any actions takenReduced dosageIncreased dosageMedication withdrawnMedication administered againNo action takenUnknown5) IMPORTANT INFORMATIONAdverse effects. Please list the symptoms Did adverse effects remit after the medication was withdrawn or the dosage was reduced?YesNoUnknownNot applicableAdverse effects. Please list the symptoms Did adverse effects occur again after the medication was administered for the second time?YesNoUnknownNot applicableIn case of death, please list the reason and date of death: Was the postmortem examination performed?YesNoIf ‘Yes’, please attach the results/report 6) OTHER MEDICATION USED (drugs interacting with the suspected medication should be listed in Table 4)Name of medication and/or the active substance* Indication(s) Dosage, route of administration, pharmaceutical form Therapy type* Start date of administration End date of administration *C – medication administered at the same time; T – medication administered to combat adverse effects; P – medication withdrawn before adverse effects were observed7) MEDICAL HISTORY: PAST AND CURRENT ILLNESSES Cigarettes Alcohol Allergies (To what?)