INFORMATION CARD

on adverse medicine reaction for consumers

1. Patient information

customer’s name* age* diagnosis* address* gender* man woman tel / fax*

2. Information about the suspected medicine

Trade mark* dosage form* manufacturer *

3. Information on the appointment of the suspected medicine

the suspect medicine was prescribed by a doctor * Yes No patient applied the suspected drug without a prescription* Yes No description of the occurrence of an adverse reaction or indication of lack of efficacy*

4. Information about the notifier

notifier’s name* address* email* tel / fax*

5. Information about the doctor and the establishment of health protection

Doctor’s name* name of the health protection institution* Address of the health protection institution* tel / fax*