Report an adverse reaction Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Reporter *For myselfOtherA. Patient informationLayout1. Patient identifier *2. Date of birth *3. Gender *MaleFemalePrefer not to discloseWeightB. Adverse event, product problem1. Type of ReportAdverse EventProduct ProblemProduct UseMedication ErrorProblem with Different Manufacturer of Same Medicine(check all that apply)Layout (copy) (copy)2. Outcome Attributed to Adverse Event *Death (Date of death)Life-threateningHospitalizatonImportant Medical EventsDisability or Permanent DamageCongenital Anomaly/Birth DefectsPermanent Prevent Impairment/Damage(check all that apply) 2. Date of death *Layout (copy)3. Date of Event4. Date of This report5. Select reaction/Symptom If one of the above points does not suit you, please add it yourself:Anemia vitamin B12 deficiencyAnemia vitamin B12 deficiencyIron deficiency anemiaTachycardiaBradycardiaArrhythmiaArterial hypertensionArterial hypotensionHaemorrhageConstipationDiarrheaNauseaVomitngDry mouthAbdominal painAbdominal discomfortFlatulenceRefluxEructationStomatitisAcute pancreatitisSwollen tongueTooth acheGinvitisLiver dysfunctionHepatitisGallbladder dysfunctionLiver painRashDermatitisRednessDry SkinUrticariaPsoriasisEczemaPruritusAlopeciaSkin ExfoliationBlistersPigmental SpotsNail DisorderFungal InfectionsGangreneSwellingPurulent RashesRosaceaSkin DisorderHair LossSkin DiscolorationNail DiscolorationAnaphylactic ShockAllergic ReactionThyroid DysfunctionDysfunction Of The PancreasHypothyroidismHyperthyroidismAutoimmune ThyroiditisDiabetesAdrenal DysfunctionSex Hormones DysfunctionItching In The GenitalsVaginal HemorrhageMenstruation DisorderProstatitisFungal Infections Of GenitalsBreasts PainGenitals DiscomfortRash In GenitalsSexual DysfunctionRenal FailureAcute Kidney InjuryKidney PainUrinary RetentionUrinary IncontinencePain UrinationPain In The BladderFatigueWeaknessDizzinessDrowsinessPainInsomniaMalaiseDeterioration Of General ConditionPyrexiaChillsGait DisturbanceMotor Functions DisorderSwollen FaceThirstIncreased Feeling Of HungerIncreased AggressivenessDecreased ActivityVestibular DisorderTinnitusDeafnessSeasicknessBlurred VisionBlindnessVisual ImpairmentEar PainTremorLoss Of ConcentrationComaFaintingApathyLoss Of AppetiteDepressive DisorderLoss Of BalanceMemory ImpairmentMigraineSpeech DisorderLimb ParalysisFacial ParalysisBone PainMuscle SpasmMuscle Weakness6. Relevant Test / Laboratory Data7. Other History, Including Preexistng Medical ConditionsC. Product Availability1. Product Available for Evaluation?YesNoLayout (copy) (copy)Returned to ManufacturerDate of return2. Do you have a picture of the product? Click or drag a file to this area to upload. D. Suspect ProductsName, Strength, Manufacturer/Compounder (from product label)Does this involve cosmetic, dietary supplement or food medical food?E. Suspect Medical Device#1. Name#2. Manufacturer/Compounder1. Brand Name2. Common Device Name3. Procode4. Manufacturer Name, City and state5. Model6. Lot7. Catalog8. Expiraton Date9. Serial10. Unique Indentifier11. Operator of DeviceHealth profesionalPatient / ConsumerOther2. Dose or Amount (mg/kg/g/mkg)FrequencyRoute3. Treatment Dates/Therapy DatesStart:End:4. Diagnosis for useIs therapy still on-going?YesNo5. Product TypeOTCCompoundedGenericBiosimilar(check all that apply)6. Event Abated After Use stopped or Dose Reduced?YesNoDon't applyF. Other Concomitant Medical Products1. Product names and therapy datesG. ReporterLayoutFisrt name *Last name *PhoneEmail *CountryPostal code2. Health Professional?3. Occupation4. If you do NOT want your identity disclosed to the manufacturer,please mark this box5. Also Reported toManufacturer/CompounderUser FacilityDistributor/ImporterSubmit
