Basic information

Information about the person reporting the adverse reaction

First name:

Last name:

Middle name:

Phone

E-mail:

Country:

Region

Details of the person who used the medicinal product

First name:

Last name:

Middle name:

Date of birth

Weight

Height

Sex

Male

Female

Country:

Region

Information about the suspected medicinal product

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

Attach a file:

Detailed information on the suspected medicinal product and concomitant medicinal products

Suspect drug

Indications for use:

Single dose

Frequency

Route of administration:

Treatment:

Actions taken with the medicinal product:

Date:

Appearance of the medicinal product:

Information about the solvent

Was a solvent used?

Yes

Add information about the solvent for the medicinal product, if applicable

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

Add information about medicinal products used together with the suspected product and during the 3 months before its use began

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:

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Reporting form to be sent to the pharmacovigilance service for GEROPHARM medicinal products for patients

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