Specialists - Biopharma

Full name *

Number of case history/outpatient card
Fill in this field!
Date of birth / age

Sexmalefemale

Weight

Onset of AR/LE

End of AR

description of AR/ indicate LE of the MP *

(including data on laboratory and instrumental studies related to AR)

Brand name, formulation *
Manufacturer *
Batch number
Indications for use
Single dose
Application multiplicity
Administration route

Start of suspected drug therapy
don't know
End of suspected drug therapy
Treatment is continuing

Cancellation of suspected drug

Was suspected drug cancellation accompanied by the termination of AR?

yesno

Change of suspected drug dosage regimen

Increase/decrease, indicate increment

Repeated prescription of suspected drug

Is there a recurrance of AR after re-appointment of the suspected drug?

yesno

Is there a recurrance of AR after сhange of suspected drug dosage?

yesno

AR/LE Correction of AR/Le was not conductedDrug treatment of AR/LE

Specify the drug, dose regimen, duration of appointment

Full name of reporter*

Telephone number *
e-mail
Name and address of healthcare institution