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Adverse medication reaction reporting form

    Patient information

    Information about the notifying person

    Description of the adverse effect/diagnosis. If no diagnosis, please specify symptoms*

    Description of the side effect

    Date of onset of symptoms

    Did the side effect disappear after stopping the drug or reducing the dose?

    Did the adverse reaction occur again after repeated administration of the medication?

    A drug that may have caused an adverse reaction

    Other medicines used

    If you were taking other medications at the same time (that could have caused the interaction) please provide information about them

    Medical history: Past and concomitant diseases

    Personal data processing