1. Full Name
3. Phone number, including area code
4. Email address
7. Date of Birth (Day/Month/Year)
8. Weight in Kg
9. Height in cm
10. The adverse reaction started on (Day/Month/Year)
11. Describe the symptoms of the Adverse Reaction (IN ORDER OF APPEARANCE)
12. How long was the medication used before the adverse reaction occurred?
Do you remember which medication?
14. Has the adverse reaction resolved?
15. Has the adverse reaction affected your daily life?
16. Has the adverse reaction caused any of the following situations?
17. The reaction ended on (Day/Month/Year)
18. Name of the medication (including brand name)
19. Pharmaceutical form and strength (amount contained in each tablet, capsule, or pill, or amount in mg per 5 milliliters – cubic centimeters if liquid – or per ampoule if injectable)
20. Batch number and expiration date of the medication (Day/Month/Year)
21. Reason for treatment (why are you taking it)
22. Dose
23. Treatment start date (Day/Month/Year)
24. Treatment end date (Day/Month/Year)
25. Was there any change in the treatment when the adverse reaction occurred?
26. What happened when the treatment changed?
27. If the medication was reused, did the reaction reappear?
28. Where was the medication obtained?
29. Name of the medication or herbal remedy
30. Reason for the treatment
31. Treatment start date (Day/Month/Year)
32. Treatment end date (Day/Month/Year)
33. Additional information about other medications
34. Any additional information
35. Have you informed any healthcare professional about the adverse reaction?
36. Were any tests or examinations performed?