Adverse Effect Reporting Form

This Form is addressing patients and their relatives. Please fill in all fields marked with * and try to provide as much information as possible!

1. INFORMATION ABOUT PERSON WHO HAVE A SIDE EFFECT

Name-Surname Initials

Gender

Age

Height

Weight

Other Informations Does the patient have medical history, diabetes, high blood pressure, allergies, etc., is the patient pregnant, if she is pregnant, the last menstrual dates, etc.

2. INFORMATION ABOUT SIDE EFFECTS

* Describe the Side Effect Experienced and How It Occurs:

When did it started? * If the exact date is unknown, you can write down how long after the side effect occurred after you started using the drug

* How Did the Side Effect Affect the Patient's Life? Please mark the appropriate option.

What is the Current Situation of the Person Experiencing the Side Effect?

Can You Provide More Information? *Örneğin hasta yan etkinin tedavisi için başka ilaçlar kullandı mı? Yan etki nedeniyle ilacı almayı bıraktı mı?

Information About Side Effects Medication

Name of the drug

Dosage (Örneğin : 100 mg günde 3 defa. )

Use of the drug

Starting date

Ending Date

Has Drug Use Has Been Discontinued Due To Side Effects?

Are There Other Medicines Used Concurrently?

Other Drug Information

Other Drug Name

Dosage (Örneğin : 100 mg günde 3 defa. )

İlacın Kullanım Nedeni

Starting date

Ending Date

Information about the Person Reporting Side Effects

Name

Surname

Phone

E-mail Address

Address information

Doctor's Name - Surname - Address or Institution of Employment:

If we need detailed medical information, do you approve to contact your doctor?

Adverse Effect Reporting Form | Maxicells

You can report us your notifications regarding any adverse effects either by filling out the form on the side or by downloading the form below on your computer and filling it out. Yan Etki Bildirim Formu