Form for medical / pharmaceutical worker

http://


    primaryfinal


    І. PATIENT INFORMATION


    malefemale


    recovery without consequencesrecovery with consequences


    ІІ. INFORMATION ABOUT SE / LE


    ІІІ. INFORMATION ABOUT SUSPECTED DRUG (SD), MANUFACTURER OF SD


    yesnounknown


    similarotherunknown


    ІV. INFORMATION ABOUT RELATED DRUGS (with the exception of drugs that were used to correct the effects of SE)


    V. MEANS OF CORRECTING SE


    yesno


    yesno


    yesno


    yesno


    VI. CAUSAL RELATIONSHIP BETWEEN CLINICAL MANIFESTATIONS OF SE AND SD

    SE- side effects

    SR-side reaction

    LE- lack of effectiveness

    SD-suspected drug