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Home Pharmacovigilance Form of adverse reaction

Form for reporting adverse reaction

 

Instructions for completing form

Do not hesitate to send a message even if you do not have all the required information at your disposal.

This document is confidential.The information from your messages is processed, respecting the Privacy Policy. The identity of the patient is never disclosed.

Please use this form to notify of any suspected ADR, caused by the use of "Unipharm JSC" drugs.

We will gratefully accept all messages send by physicians, dentists, pharmaceutists or other medical experts. Patients who assume that adverse reactions are showing due to use of prescribed medicaments, can notify of it via their physician.

Messages about drug reactions can also be sent to:

Phone: (02) 817 74 13
Fax: (02) 974 37 59
Email: safety@sopharma.bg


Patient Data
Initials of patient:
Sex:
Date of birth:
Age:

Data on drug suspect
Suspected medicinal product (brand name):
Pharmaceutical form:
Dose, frequency of intake, route of intake:
Purpose (reason for the adoption of the drug):
Beginning the Treatment:
End of the treatment:
I was stopped admission of suspected drug?:
Have a patient suspected drug before:

Other medicines taken at the same time
Medicine (trade name):
Pharmaceutical form:
Dose, frequency of intake, route of intake:
Indication:

Adverse Drug Reaction
Description of adverse reaction:
Data on adverse event
Start Date:
End Date:
Exit adverse reaction:
Relationship between implementation of the suspect:
Additional information:
Time of occurrence of adverse reaction after
use the medicine, details of treatment
effects, concomitant therapy
history of the disease.

I was led to adverse reaction
Hospitalization / extended stay at hospital:
Life-threatening condition:
Permanent and substantial disability:
Intervention to prevent the above:
Hereditary abnormality or birth defect:
Is patient deceased?:

Details of the person giving information
Medical specialist:
Name:
Address:
Contact phone:
E-mail:
Profession:
Is the message sent to the IAL?: