Farmacovigilância

Reporter

Name *

E-mail *

Phone

Are you a medical professional? *

Yes

No

I am... * Professional subscription State

Are you linked to a health institution or hospital? *

Yes

No

Which institution? *

Patient

Initials or Name

Gender

Male

Female

Unkown

Pregnant?

Yes

No

Date of last period

How many gestational weeks?

Weight (kg)

Age

Height (cm)

Product

Eurofarma Product *

Lot

Why do you use

Administration route

How it is used (quantity and how many times a day)

Treatment start

Treatment end

Patient's clinical history

Does the patient have any disease?

Yes

No

Disease name

Diagnosis date

Does the patient use any other medication?

Yes

No

Please list other adverse events below, if any Add medicine

Adverse Effects (AE)