Evento Adverso – Ecuador

    A. Patient Information


    MaleFemaleUnknown

    B. Drugs

    Mention the name of drugs patient is currently using, whether prescribed or not. Include: self-medication, herbal medicine, teas and others. Suspicious ones to be mentioned first. Do not mention those used for reaction treatment.

    Obs.: Note: If necessary, send us additional information using a new form.

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    C. Adverse reaction description

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    Clinical report

    D. Concomitant diseases


    YesNoNot informed

    E. Additional information

    YesNo


    YesNoNot applicable or unknown


    YesNoNot applicable or unknown

    YesNoNot applicable or unknown


    YesNoNot applicable or unknown


    YesNoNot applicable or unknown


    YesNoNot applicable or unknown

    YesNo

    F. Primary notifier information


    PhysicianDentistPharmacistOther

    *Required fields