INFORMATION ABOUT PATIENT

Initials

Country

Date of birth

Age (years)

Gender
MF

INFORMATION ABOUT AR/LE

AE Category
Death of patientLife-threateningHospitalization of ambulatory patient or prolongation of hospitalizationTemporary or considerable disability, invalidityCongenital malformationsNone of the above

Date of report

Description of AR

Onset of AR

End of AR

INFORMATION ABOUT SUSPECTED MEDICINAL PRODUCT (SMP)

SMP (trade name, dosage form)

Single dose and dose frequency

Indication for prescription
MedicalSelf-medication

Concomitant Medicines

Therapy date From

Therapy date To

INFORMATION ABOUT SOURCE

Initials

Status
Health workerMedical representativePatientOther

Address

Phone/Fax

E-mail (required)

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