A. Patient Information Patient Identification (initials or Code) * Age or Birth Date * Weight * Gender MaleFemaleUnknown Primary diagnosis* In case of pregnancy, indicate pregnancy time upon adverse reaction 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. 1 Trade or generic name* Dosage * Route of administration* Starting date of use * Last date of use * Reasons for use * Batch 2 Trade or generic name Dosage Route of administration Starting date of use Last date of use Reasons for use Batch 3 Trade or generic name Dosage Route of administration Starting date of use Last date of use Reasons for use Batch 4 Trade or generic name Dosage Route of administration Starting date of use Last date of use Reasons for use Batch 5 Trade or generic name Dosage Route of administration Starting date of use Last date of use Reasons for use Batch C. Adverse reaction description 1 Reaction * Starting date End date Evolution * 2 Reaction Starting date End date Evolution 3 Reaction Starting date End date Evolution 4 Reaction Starting date End date Evolution 5 Reaction Starting date End date Evolution Clinical report Clinical report on the case and on the adverse reactions, including relevant laboratory data * D. Concomitant diseases ---Blood hypertensionDiabetesCardiopathyNephropathyHepatopathyAlcoholismTabagismNot informed Allergy or previous reaction to drug? YesNoNot informed Mention other concomitant diseases. Mention information related to allergy or previous reaction to drug E. Additional information 1. Death?? YesNo 2. Was hospitalization necessary? YesNoNot applicable or unknown 3. Prolongou a internação? YesNoNot applicable or unknown 4. Prolongou a internação? YesNoNot applicable or unknown 5. Reaction disappeared/improved after discontinuing medication YesNoNot applicable or unknown 6. Reaction disappeared/improved after dosage adjustment YesNoNot applicable or unknown 7. Was the event recurrent after re-introduction of medication? YesNoNot applicable or unknown 8. Did you previously notify this case YesNo Causa mortis When? F. Primary notifier information Name * Date of notification * Professional category * PhysicianDentistPharmacistOther Council registration number Others specify State Telephone Email * *Required fields
