Information about the patient Full name Number of the medical history / ambulatory card Date of birth Paul MaleFemale Weight (kg) Height (cm) Suspected PR/OE Suspected PR / Indication OE Start date of PR/OE End date of PR/OE PR/OE correction Without treatmentNon-drug treatmentDrug therapySurgical interventionDialysis PR/OE consequence Recovery without consequencesRecoversNo changesRecovery with consequencesDeathUnknown These manifestations of PR are considered serious (applies to the case of PR as a whole) YesNo Information about suspected drugs Suspected drugs (trade name, dosage form, manufacturer) Serial number Indications (if possible according to ICD-10) The force of action Single dose Multiplicity of reception Method of administration Date and time of therapy initiation Date and time of termination of therapy Measures that were taken in relation to suspected drugs for the correction of PR/OE Cancellation of the suspected drugNot used (for example, if suspected drugs are used once)Drug therapy of PR/OE (drugs, potency, duration of appointment are indicated)Unknown Were the suspected drugs prescribed again? YesNo Did the PR/OE occur again after re-appointment of the suspected drug? YesNo Information about accompanying drugs (with the exception of drugs that were used to correct the effects of PR/OE) Concomitant drugs (trade name, dosage form, manufacturer, batch number) [text* lsсoncomitant-1-form-1] Indications (if possible according to ICD-10) The force of action Single dose Multiplicity of reception Method of administration Date of initiation of therapy End date of therapy The second important information Information about the notifier Full name Specialty Health care institution Location Email address Tel. Date Information about the medical/pharmaceutical specialist (if not the notifier) Full name Specialty Health care institution Location Email address Tel Date
