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Online Form for Medical Inquiries, Complaints, Adverse Reaction Report
Reporter Information
Helpdesk-Team
Typ of Request
Adverse Reaction Report
Complaint
Medical Inquirie
Subject
E-Mail
Title
First name
Surename
Organisation
Department
Address (Street)
Postal code ZIP
City
Country
Telefone
Mobile
Prevered Language
German
English
Reporter Type
Doctor
Pharmacie
Patient
Nurse
Family member
Business Partner
Product Information
Product/Tade name
Batch Number(s)
Product Category
Pharmaceutical Product
Medical Technical Product
Food Supplements
Product Sample
Comments to Sample
Indication for use
Daily dosis
Route of Administratiom
Begin of Treatment
End of Treatment
Duration of Use
Duration of Use before
Reaction Details
Describe Reaction(s)
Date of Reaction
Duration of Reaction
Life threatening
Patient hospitalised
Hospitalisation prolonged
Congenital anomaly or birth defect
Persistent or significant disability/incapacity
Patient deceased by side effect
not applicable
Action
Drug discontinued
Drug continued
Dosage changed
Therapy
Outcome
Restored
Improved
Unchanged
Worsen
Fatal
Unknown
Patient Information
Patient Initials
Date of birth
Gender
Male
Female
Height
Weight
Week of pregnancy
Relevant Medical History
Nicotine
Alcohol
Allergies
Drug abuse
Metabolic disorder
Other
Risk Descritption
Remarks
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