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Questionnaire for medical workers
Reporting form to be sent to the pharmacovigilance service for GEROPHARM medicinal products for medical professionals
Confidential if filled in. You can send the form at any stage of its filling in
Page
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Information about the person reporting the adverse reaction
First name:
Last name:
Middle name:
Phone
E-mail:
Country:
Region
Organisation, address:
Position:
Patient details
First name:
Last name:
Middle name:
Date of birth
Weight
Height
Sex
Male
Female
Country:
Region
Medicinal product information
Medicinal product (trade name, pharmaceutical form)
Batch No.
Start date of administration:
End date of administration:
Adverse reaction information
Please describe the adverse reaction
Start date:
End date:
Outcome of the adverse reaction
Recovered without consequences
Condition improved
No change
Recovered with consequences
Death
No information
Is the reaction serious?
Yes
No
Seriousness criterion:
Fatal outcome
Life-threatening
Hospitalisation or prolonged hospitalisation
Disability/incapacity
Congenital anomalies/birth defects
Other clinically significant event
Attach a file:
Detailed patient information
Comorbidities
Condition:
Start date:
End date:
Test/procedure name:
Date:
Result:
Smoking
Yes
No
Former smoker
Alcohol
Yes
No
Previously used
Drugs:
Yes
No
Previously used
Renal insufficiency
Yes
No
No information
Hepatic impairment
Yes
No
No information
Allergy information
Allergy
Yes
No
Allergy description:
Test/procedure name:
Date:
Result:
Pregnancy
Pregnancy
Yes
No
Pregnancy term:
Detailed information on the suspected medicinal product and concomitant medicinal products
Medicinal product (trade name, pharmaceutical form)
Indications for use:
Single dose
Frequency
Route of administration:
Date:
Appearance of the medicinal product:
Treatment:
Outpatient
Inpatient
Self-treatment
Actions taken with the medicinal product:
Medicinal product withdrawn
Dose reduced
Dose increased
Dose unchanged
No information
Not applicable
Medicinal product temporarily interrupted
Information about the solvent
Was a solvent used?
Yes
No
Добавьте сведения о растворителе для лекарственного препарата, если применимо
Medicinal product (trade name, pharmaceutical form)
Volume:
Concentration:
Start date:
End date:
Have you ever used this solvent before? When? Was it well-tolerated by you?
Information about the concomitant therapy
Добавьте сведения о лекарственных препаратах, которые применялись одновременно с подозреваемым препаратом и за 3 месяца до начала его применения
Medicinal product (trade name, pharmaceutical form)
Single dose
Frequency
Route of administration:
Indication for use:
Start date:
End date:
Has this medicinal product been used before? When and how was it tolerated?
Actions taken to correct the adverse reaction
Measures:
No treatment
Changes in concomitant therapy
Drug therapy
Non-drug therapy (including surgical intervention)
Other
Specify other:
Assessment of the causal relationship between use of the suspected medicinal product and the adverse reaction
Assessment comment, including the causal relationship:
Details:
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You are a health care professional?
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