Medical specialists

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To be filled by medical and pharmaceutical specialists

    1. General information
    Gender*
    Consequence of adverse reactions/lack of effectiveness*
    Category of adverse reactions/lack of effectiveness*
    2. Information about the suspected medicine
    3. Information about concomitant medications
    4. Means for correcting adverse reactions
    Was discontinuation of the suspected medicine accompanied by the disappearance of adverse reactions?
    Has a resumption of adverse reactions been noted after re-prescribing the suspected medicine?
    Has a resumption of adverse reactions/lack of effectiveness been noted after changing the dosage regimen of the suspected medicine?
    5. Information about the notifier
    Message provides*