Adverse event (AE) form

Report*

Initial

Secondary

Patient's information

Full name*

Date of birth*

Sex*

Male

Female

Height (cm)

Weight (kg)

Treatment

Outpatient

Inpatient

Address

Telephone

E-mail*

Information about the person who prescribed the treatment

Source*

Full name*

Address

Telephone*

E-mail

Medicinal product suspected of causing AE

Name of the medicinal product*

Indications*
for this medicinal product administration

Route of administration

Daily dose

Product shelf life

Batch

Medication start date

Medication end date

Manufacturer information:

AE presumably associated with the medicinal product administration

List the symptoms*
(e.g., nausea,
headache, itching,
skin rash)

AE onset date

AE end date

AE outcome:

Actions taken

Additional information on AE

Any additional information on AE, any performed therapy, studies performed

Concomitant therapy within the last 3 months
(including medicinal products and dietary supplements used for self-medication)

Name of the medicinal product

Route of administration

Therapy start date

Therapy end date

Indications

List comorbidities

Social habits

Allergic reactions to medication

Attention!

Adverse event (AE) form

Patient's information