LIMENDA

PROVE YOU ARE A MEDICAL PROFESSIONAL

Attention: This section is intended for healthcare professionals only. If you are not a medical professional, you can return to the main page by clicking the “No” option

CARD-NOTIFICATION OF AN ADVERSE DRUG REACTION AND/OR LACK OF EFFICACY OF THE MEDICINE

INFORMATION ABOUT THE PATIENT

Full name *

Medical history/outpatient record number *

Date of birth/age *

Gender *

Man
Women

Weight (kg) *

Height (cm)

SUSPECTED AR/LE

Suspected AR (describe each clinical manifestation of the AR with dates and times of onset and end and outcome)/Indication of the LE

Date and time of the start of the AR / LE / *

Date

Time

Date and time of the end of the AR/LE/ *

Date

Time

Correction of the AR/LE: *

Consequence of the AR/LE *

Whether these manifestations of the AR are considered serious (refers to the case of the AR in general)

Yes
No

If yes, indicate why the AR is considered serious (one or more reasons are indicated): *

INFORMATION ABOUT SUSPECTED MEDICINES

Suspected medicines, vaccine, tuberculin (trade name, dosage form, manufacturer) *

Series number *

Indications (if possible according to ICD-10) *

Power of action *

Single dose *

The frequency of intake *

How to input *

Date and time of therapy start

Date

Time

Date and time of completion of therapy

Date

Time

Measures taken with respect to suspected medicinal products to correct AR/LE

Whether the suspected drugs or vaccine were prescribed repeatedly *

Yes
No

If so, it is indicated whether it was:

Whether the AR/LE reoccurred after re-administration of the suspected drug *

Yes
No

INFORMATION ABOUT RELATED MEDICINES

(with the exception of drugs used to correct the effects of AR/LE)

Related medicines, (trade name, dosage form, manufacturer, serial number)

Indications (if possible, according to ICD-10)

Power of action

Single dose

Frequency of administration

How to input

Start date of therapy *

End date of therapy *

Other important information

(concomitant diagnoses, laboratory and instrumental studies, allergy history, pregnancy with gestational age, method of conception, pregnancy outcome (if the pregnancy ended, the date of delivery, type of delivery, etc.)

Information about the messenger

Full name *

Specialization *

Health care facility *

Address *

E-mail *

Phone *

Date

INFORMATION ABOUT THE MEDICAL/PHARMACY SPECIALIST

(if not the notifier)

Full name

Specialization

Health care facility

Location of the healthcare facility

Address

E-mail

Phone

Date.

MESSAGE CARD for the patient

to provide the patient and/or his/her representative with information on adverse drug reactions and/or lack of efficacy of the drug

INFORMATION ABOUT THE PATIENT

Full name *

Address *

Tel./fax *

Information about the suspected medicine

Layout

Trade name *

Manufacturer *

Form of issue *

Information on the prescription of the suspected medicinal product

The suspected drug was prescribed to the patient by a doctor *

Yes
No

The patient used the suspected drug without a doctor's prescription *

Yes
No

Description of manifestations of adverse drug reactions and/or indication of the lack of efficacy of the drug *

Information about the messenger

Full name *

Address *

Tel./fax *

Information about the physician, healthcare facility and place of residence of the patient who had an adverse medicine reaction and/or lack of efficacy of the medicine

Full name *

Location of the healthcare facility *

Tel./fax

Name of the health care institution where the attending physician works

Patient's place of residence

LIMENDA

products from category

PROVE YOU ARE A MEDICAL PROFESSIONAL

CARD-NOTIFICATION OF AN ADVERSE DRUG REACTION AND/OR LACK OF EFFICACY OF THE MEDICINE

INFORMATION ABOUT THE PATIENT

SUSPECTED AR/LE

INFORMATION ABOUT SUSPECTED MEDICINES

INFORMATION ABOUT RELATED MEDICINES

Information about the messenger

INFORMATION ABOUT THE MEDICAL/PHARMACY SPECIALIST

MESSAGE CARD for the patient

INFORMATION ABOUT THE PATIENT

Information about the suspected medicine

Information on the prescription of the suspected medicinal product

Information about the messenger

Information about the physician, healthcare facility and place of residence of the patient who had an adverse medicine reaction and/or lack of efficacy of the medicine