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Reporting Form for Suspected Adverse Reactions to Medications or Other Pharmaceutical Products by Healthcare Professionals
Patient or User Data
Gender
Male
Female
Suspected Adverse Reactions
Select the option if the notification corresponds to:
Select
Adverse Reaction
Medication Error
Quality Issue
Other (Specify)
Select the severity of the RAM:
Select
Mild
Moderate
Severe
In case of Severe RAM:
Select
Death
Placed the patient's life at serious risk
Caused or prolonged hospitalization
Caused disability/incapacity
Caused a congenital anomaly
If you choose "Death":
Outcome:
Select
Recovered
Not Recovered
Recovered with Sequelae
Fatal
Unknown
Suspect Drug(s) or Other Pharmaceutical Product(s)
Did the adverse reaction disappear after discontinuing the medication or other pharmaceutical product?
Select
Yes
No
Not Applicable
Did the adverse reaction disappear when the dose was reduced?
Select
Yes
No
Not Applicable
Did the adverse reaction recur when the drug or other pharmaceutical product was administered again?
Select
Yes
No
Not Applicable
Has the patient previously experienced an adverse reaction to a medication or other pharmaceutical product?
Select
Yes
No
Not Applicable
Did the patient receive treatment for the adverse reaction?
Select
Yes
No
Please specify your answer:
In case of suspected quality problems, indicate:
In case of suspected quality problems, indicate:
Concomitant Medication(s) or Other Pharmaceutical Product(s) Used in the Last 3 Months
Notifier Data
Send
Escríbenos
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