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Advers Reaksiyon Formu
Advers Reaksiyon Formu
PATIENT INFORMATION
Date of Notification
Initials of the Patient´s Name and Surname
Date of birth
Age,Length,Weight
Gender
Adverse Effect(s)
1-) Define Adverse Effect
Starting date
End Date
2-) Define Adverse Effect
Starting date
End Date
3-) Define Adverse Effect
Starting Date
End Date
Result
Other
Related Medical History / Concurrent Diseases
(For example: Allergy, pregnancy, smoking and alcohol use, hepatic / renal insufficiency, diabetes, hypertension, etc.) For congenital anomalies, indicate the last menstrual history with all the medications and the diseases the mother is receiving during pregnancy (Day / Month / Year)
History
USED MEDICAL PRODUCTS(S)
Name of Suspected Drug
Delivery Road
Daily Dose
Pill Begin Date (Day / Month / Year)
(If more than one drug is present, indicate with the start dates.)
1-) Pill Begin Date
2-) Pill Begin Date
3-) Pill Begin Date
Date On Which The Drug İs Not Used (Date/Month/Year)
1-) Date On Which Drug Is Not Used
2-) Date On Which Drug Is Not Used
3-) Date On Which Drug Is Not Used
Indication
(Reason for using medication)
Is the medicine broken?
(If you have more than one drug, choose the option that is appropriate for each drug.)
1. Drug use stopped?
2. Drug use stopped?
3. Drug use stopped?
Is Adverse Effect Reduced When Drug Is Not Used or Decreased Dosage
(If you have more than one drug, choose the option that is appropriate for each drug.)
1. Is Adverse Impact Reduced?
2. Is Adverse Impact Reduced?
3. Is Adverse Impact Reduced?
Was the drug reused?
(If you have more than one drug, choose the option that is appropriate for each drug.)
1. Was the drug reused?
2. Was the drug reused?
3. Was the drug reused?
Did the Adverse Effect Repeat Repeat Drug Use?
(If you have more than one drug, choose the option that is appropriate for each drug.)
1. Has the Adverse Effect Repeated Over the Drug Reuse?
2. Has the Adverse Effect Repeated Over the Drug Reuse?
3. Has the Adverse Effect Repeated Over the Drug Reuse?
Concurrently Used Drug (s)
(Excluding those used for the treatment of the Adverse Effect)
INFORMATION REGARDING A NOTICE
Name and surname
Job
Telephone
Address
Email