Step 1 of 4 25% ON PATIENT INFORMATIONINITIALSETHNICITYAGEWeightSEX Female Male Main DiagnosisConcomitant disease/diseases(please indicate a hospital if appropriate)Please, indicate information hypersensibility to drugs allergies abuse of alcochol HRT, contraceptive therapy pregnancy ADVERSE DRUG REACTIONADVERSE DRUG REACTION (ADR) DESCRIPTION* (symptoms, results of the analysis, changes in laboratory data range, drugs used for the ADR treatment) ONSET Time : HH MM END Duration(if continued less than 24 hours, specify hours) Adverse Drug Reaction caused: Patient’s death Hospitalisation or prolongation of existing hospitalisation Results in persistent or significant disability or incapacity (underline appropriate) Life-threatening Congenital anomaly/birth defect Other medically important case Other Patient’s death dataPlease specify the other medically important casePlease specify the other caseOutcome of the Adverse Drug Reaction: Complete recovery Not resolved, without sequel Not resolved, with sequel Ongoing Not known Please, specify the sequel (if not resolved, with sequel)Was the use of drug terminated when adverse reaction appeared? Yes No Unknown Did reaction dissappear after withdrawing the drug? Yes No Unknown Did reaction dissappear after reducing the dosage? Yes No Unknown Did reaction reappear after renewing the drug intake? Yes No Unknown Did reaction reappear after increasing the dose? Yes No Unknown SUSPECTED DRUG WHICH MIGHT CAUSE ADVERSE DRUG REACTIONTrade name, drug form, active substance and manufacturerIndications for useRoute of administrationDose, units, frequencyStart dateEnd dateBatch/ Series No.Are the drugs taken for the first time in life?If drugs were applied earlier, were the reactions similar? CONCOMITANT DRUGS USED IN LAST 3 MONTHS (INCLUDING SELF-TREATMENT)Trade name, drug form, active substance and manufacturerIndications for useRoute of administrationDose, units, frequencyStart dateEnd dateBatch/ Series No. REPORTER (doctor or pharmacist)Name* First Last PhoneEmail SPECIALITY/QUALIFICATION(physician, pharmacist, other health professional : please – specify)Date of report Office Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country ADDITIONAL INFORMATION(e.g.: on serious concomitant disease, allergic reactions, increased drug sensitivity, pregnancy, significant laboratory test results) Agreement*I understand that by signing and/or sending the report I give the permission to the staff of JSC Olainfarm to contact me in order to clarify the information referred to into the report and ask the necessary questions. I agree. This iframe contains the logic required to handle Ajax powered Gravity Forms. Adverse Drug Reaction Form TEST12.28.2015