Evento Adverso – Paraguay

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