Drug reactions

+359 2 437 23 16

info@fortex.bg

или денонощно:

+359 895 60 66 15; +359 2 465 11 43

Please fill all required fields!

Details of the person giving the information

Healthcare professional *

Name *

Work address

Contact phone *

E-mail

Patient data

Name, Surname / Initials *

Gender *

Age

Suspected medicinal product

Medicinal Product (name of the medicinal product or active substance(s)) *

Dosage form / unit

Batch Number

Daily dose

Start of treatment

End of treatment

Method of administration

Indications / reason for taking the medicine

Has the patient used the same medicinal product before?

Have measures been taken to treat the reaction?

Action taken with the drug?

If there is more than one suspected medicinal product, please add it in an additional field by clicking on the "Add suspected medicinal product" button

Adverse drug reaction

Description of the adverse drug reaction *

Start date

End date

Outcome

Causal relationship

Did the reaction abate after stopping the drug?

Did the reaction reappear after reintroduction of the drug?

Did the adverse drug reaction lead to Fatal Life-threatening Inpatient hospitalization/ prolongation of existing hospitalization Persistent of significant disability/ incapacity Congenital anomaly Other important medical events

For Reports of Patient Death

Autopsy performed?

Autopsy data

If you agree to seek further information on this matter from your healthcare professional, please provide contact details.

More information

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