Adverse drug reactionPlease use this form to report any suspected adverse drug reactions observed with the use of medicines by Adifarm EAD. Do not hesitate to send a message even when you do not have all the necessary information to fill out the form! Contact Person - Olyana Zaneva+359 2 892 10 74 (24/7)pv@comac-medical.comThe information you provide us is extremely important to detect unknown adverse drug reactions to Adipharm EAD medicinal products. We will need your contact details to: Feedback to confirm receipt of the message; if we need to request additional information to evaluate the alert for the safety of the medicinal product and to evaluate the options for minimizing or preventing the risk; to inform you of the measures taken. We assure you that the personal data of the communicator / patient is treated in accordance with the Personal Data Protection Act.Details of the person giving the informationHealthcare professional * Physician Pharmacist Other healthcare professional Patient or consumerName: *Work address: Contact phone: *Email: Patient data Name, Surname / Initials: *Gender: * Male FemaleAge: Suspected medicinal productMedicinal Product (name of the medicinal product or active substance(s)): *Dosage form / unit: Batch Number: Daily dose: Start of treatment: End of treatment: Method of administration: Indications / reason for taking the medicine: Has the patient used the same medicinal product before? Yes No UnknownHave measures been taken to treat the reaction and what?? Yes No UnknownAction taken with the drug? Drug withdrawn Dose decreased Dose increased Dose not changed Unknown Not applicableIf there is more than one suspected medicinal product, please add it in an additional field by clicking on the "Add suspected medicinal product" button Add adverse drug reaction Премахни подозиран продуктSuspected medicinal productMedicinal Product (name of the medicinal product or active substance(s)): *Dosage form / unit: Batch Number: Daily dose: Start of treatment: End of treatment: Method of administration: Indications / reason for taking the medicine: Has the patient used the same medicinal product before? Yes No UnknownHave measures been taken to treat the reaction and what?? Yes No UnknownAction taken with the drug? Drug withdrawn Dose decreased Dose increased Dose not changed Unknown Not applicableIf there is more than one suspected medicinal product, please add it in an additional field by clicking on the "Add suspected medicinal product" button Add adverse drug reaction Премахни подозиран продуктSuspected medicinal productMedicinal Product (name of the medicinal product or active substance(s)): *Dosage form / unit: Batch Number: Daily dose: Start of treatment: End of treatment: Method of administration: Indications / reason for taking the medicine: Has the patient used the same medicinal product before? Yes No UnknownHave measures been taken to treat the reaction and what?? Yes No UnknownAction taken with the drug? Drug withdrawn Dose decreased Dose increased Dose not changed Unknown Not applicableIf there is more than one suspected medicinal product, please add it in an additional field by clicking on the "Add suspected medicinal product" button Add adverse drug reaction Премахни подозиран продуктAdverse drug reactionDescription of the adverse drug reaction: *Start date: End date: Outcome: Recovered/ resolved Recovering/ resolving Not recovered/ not resolved Recovered/ resolved with sequelae Fatal UnknownCausal relationship: Definitely related Probable related Possibly related Not relatedDid the reaction abate after stopping the drug? Yes No UnknownDid the reaction reappear after reintroduction of the drug? Yes No UnknownDid the adverse drug reaction lead to Fatal Life-threatening Inpatient hospitalization/ prolongation of existing hospitalization Persistent of significant disability/ incapacity Congenital anomaly/ birth defect Other important medical eventsFor Reports of Patient Death Autopsy performed?: Yes No Unknown Add new adverse drug reactionAdverse drug reactionDescription of the adverse drug reaction: *Start date: End date: Outcome: Recovered/ resolved Recovering/ resolving Not recovered/ not resolved Recovered/ resolved with sequelae Fatal UnknownCausal relationship: Definitely related Probable related Possibly related Not relatedDid the reaction abate after stopping the drug? Yes No UnknownDid the reaction reappear after reintroduction of the drug? Yes No UnknownDid the adverse drug reaction lead to Fatal Life-threatening Inpatient hospitalization/ prolongation of existing hospitalization Persistent of significant disability/ incapacity Congenital anomaly/ birth defect Other important medical eventsFor Reports of Patient Death Autopsy performed?: Yes No Unknown Add new adverse drug reaction Премахни нежелана реакция Adverse drug reactionDescription of the adverse drug reaction: *Start date: End date: Outcome: Recovered/ resolved Recovering/ resolving Not recovered/ not resolved Recovered/ resolved with sequelae Fatal UnknownCausal relationship: Definitely related Probable related Possibly related Not relatedDid the reaction abate after stopping the drug? Yes No UnknownDid the reaction reappear after reintroduction of the drug? Yes No UnknownDid the adverse drug reaction lead to Fatal Life-threatening Inpatient hospitalization/ prolongation of existing hospitalization Persistent of significant disability/ incapacity Congenital anomaly/ birth defect Other important medical eventsFor Reports of Patient Death Autopsy performed?: Yes No Unknown Премахни нежелана реакция If you agree to seek further information on this matter from your healthcare professional, please provide contact details. More information: * I am familiar with Adifarm EAD Privacy PolicySubmit
