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Information about reporter

Name, surname *
Occupation, place of work *
Company’s address *
Phone *
E-mail *
Profession *
Treatment *

Information about patient

Name, surname *
Sex *
Age *
Weight (KGs)
Gestation period week(s)
Hepatic dysfunction
Renal insufficiency
Allergy (causes)

Adverse reaction or inefficiency of drug

Description of adverse reaction or inefficiency

The drug produced by “ARPIMED” LLC

Name, dose, dosage form, batch number

Attach file

Single dose
Daily dose
Indications for use

Therapy dates(start)
Therapy dates(end)
The dose which has caused the adverse effect

Other drugs used during the last 3 months,
including the drugs taken with ones produced by "Arpimed" LLC

(exclude those used to treat adverse reaction)
Name, dose, manufacturer, dosage form,batch number, expiry date

Single dose
Daily dose
Indications for use

Date of appointment
Date of cancellation

Outcome of adverse reaction

The degree of severity of side effects

Whether the same medicinal product was administered before? If yes, what kind of adverse reactions were observed?

Whether event abated after use stopped?

Whether event reappeared after reintroduction?

Whether event abated after dose reduced?

Important additional information

Data from clinical, laboratory and radiological examinations and autopsies, including the determination of the concentration of drug in the blood / tissues, if any, are associated with adverse reactions. Accompanying diseases. Data anamnesis, suspected drug interactions. In case of emerging congenital anomalies indicate all other drugs taken during pregnancy.