Skip to content
Tel: +372 654 5922
|
info@pharmaestica.ee
Email
LinkedIn
HOME
ABOUT US
R&D
QUALITY
PRODUCTION
PHARMACOVIGILANCE
CONTACTS
Report side effect
radmin
2019-10-24T12:10:34+03:00
Patient's first name
*
Patient's last name
*
Patient's phone number
*
E-mail address
*
Patient address
*
Suspected drug
*
Asprovit
Asprovit C
Upstinon
Mucovit 200
Mucovit 600
Padevix
Data on the user of the medicinal product
*
Gender
*
Man
Woman
Weight
*
Length
*
Adverse reactions data
*
Was the drug suspected of occurring if the adverse reaction (s) occurred?
*
Yes
No
If the drug was restarted, did the side effect occur again?
*
Yes
No
Don't know
Was the side effect:
*
Not serious
Caused disability / permanent damage
Birth defect (use during pregnancy)
Life-threatening (emergency or intensive care was required)
Other important
Hospital treatment was needed
Hospitalization was prolonged
Treatment was needed
It ended in death
Duration of side effect:
*
It still lasts
Disappeared
What other medicines did you take / did you take at the time you experienced the side effect?
*
Data on other medical conditions
Hepatic impairment
Renal impairment
Other (chronic) diseases
Do you smoke?
*
Yes
No
This medicine has been purchased
*
From the pharmacy
From the Internet
From abroad
Did you tell your doctor about the side effect?
*
Yes
No
Do you allow us to contact your doctor for further information?
*
Yes
No