mp

on adverse reactions (AR) and / or lack of efficacy (LE) of a medicinal product (MP) during its medical application

1. General information

2. Information about the suspect medicine (SM)

trade mark, dosage form manufacturer series number diagnosis dose frequency of application route of administration

start of the SM therapy

Not known still in treatment

3. Information about concomitant medication

trade mark, dosage form manufacturer series number dose frequency of application route of administration

start of the SM therapy

Not known still in treatment

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4. Medicines for AR correction

SM cancel repeating prescription of SM

Was the cancel of the SM accompanied by the disappearance of the AR? Yes No Is there a renewal of the AR after the repeating prescription of SM. Yes No

change of the dosage modification! decrease / increase, note how much

AR/LE Correction of AR/LE was not performed Medication of AR/LE

Note MP, dosage, duration of the prescription

5. Notifier’s information

notifier’s name* tel / fax* e-mail* name and address (country, city, street) of the health care institution or applicant*

notifier* pharmacist pharmaceutist doctor nurse InterChem employee other

INFORMATION CARD