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ADVERSE EVENT REPORTING FORM

I. PATIENT INFORMATION
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Initials

Sex

Date of Birth
Age

Height

cm
Weight

kg
II. ADVERSE EVENT INFORMATION
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Description of adverse event:

Classification:

Czas trwania objawów:
Reaction Start Date:

Reaction End Date:

Result:

III. MEDICATION/S SUSPECTED TO CAUSE AN ADVERSE EVENT
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Name of the medication

Batch/Lot Number:

Form of Medication

Route of Administration

Dose

Drug Start and End Date :

Indications:

Product Reaction Relatedness:
prawdopodobny możliwy prawdopodobnie brak związku brak związku niemożliwy do oceny

Actions taken related to the medication, respectively:
Dose Decreased Dose Increased odstawiony na stałe Temporarily discontinued Dose Not Changed Unknown

Add drug suspected of causing an adverse event
Other Used Medications
Name of the medication

Form of Medication/Route of Administration

Dose

Drug Start and End Date :

C T P

Add other used medications
IV. REPORTER INFORMATION
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The reporter is:

Contact details
Phone
E-mail

Date

V. ADDITIONAL INFORMATION
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Previous drug reactions, risk factors, past medical conditions and comorbiditiess, results of additional tests:

Tabacco
NIE TAK

Alcohol
NIE TAK

Allergies
NIE TAK

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