Reporter
Name
E-mail
Phone
Are you a medical professional?
Yes
No
I am...
Are you linked to a health institution or hospital?
Yes
No
Which institution?
Patient
Initials or Name
Gender
Male
Female
Pregnant?
Yes
No
Date of last period
How many gestational weeks?
Weight (kg)
Age
Height (cm)
E-mail
Phone
Medication
Eurofarma Product
Lot
Use indication
Administration route
Posology
Treatment start
Treatment end
Patient's clinical history
Does the patient have any disease?
Yes
No
Which disease?
Does the patient use any other medication?
Yes
No
Indique abaixo os outros medicamentos usados:
Adverse Effects (AE)
Description of the Adverse Effects (AE) and occurence history
Adverse Effects (AE)
Start date
End date
Ongoing?
Yes
No
Indique abaixo outros eventos adversos, se houverem:
Were the AEs treated?
Yes
No
Which treatment?
Suspended the medication use due to the AEs?
Yes
No
Prescribing doctor
Name of the prescribing doctor
Phone of the prescribing doctor
Submit report
Country:
Brazil
Language:
English