Report side effect - PharmaEstica koduleht

Reporter's first name*

Reporter's last name*

Reporter's phone number*

Reporter's e-mail address*

Are you:

Suspected drug*

Data on the user of the medicinal product

Age*

Gender*

Weight

Lenght

Data on adverse reactions*

Whether you stopped taking the medicine if you experienced an adverse effect?

Did the adverse effect occur again if the drug was restarted?

Was the adverse effect:

Duration of adverse effect:

What other medicines do you take / did you take at the time you experienced the adverse effect?

Data on other medical conditions

Do you smoke?

This medicine has been purchased

Did you tell your doctor about the side effect?

Do you allow us to contact your doctor for further information?

Name of your doctor and the health care centre