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Hot Line

Dear Doctors and Patients,

In case of undesirable reaction you can fulfill the form and send to or call to our Hot Line: +99412 404 7885 /ext. 321

We care about your Health!

The notice about undesirable reaction of medicine or absence of expected therapeutic effect.

The Doctor or other person reporting about HP


Position and work place:

Establishment address:


Information date of receipt:

Information about the patient


№ of the out-patient card or clinical record __________

Sex: o М o W

Age: _________ Weight (кg): __________

Pregnancy o Pregnancy term _____weeks

Violation of function of a liver o yes o no o unknown

Violation of function of kidneys o yes o no o unknown

Allergy (to indicate on what)

Treatment: o out-patient o stationary o self-treatment

Message: o primary

o repeated (date of the primary _________ )

The MEDICINE No. 1 which has allegedly caused HP

International Unlicensed Name (IUN)

Trade name



Series Number

The indication to appointment

Introduction way

Single/daily dose

Therapy Start date

Therapy Expiration date

Dose which has caused HP

/ /

/ /

OTHER MEDICINES accepted within the last 3 months, including PM accepted by the patient independently (according to own decision)

Specify "no" if the patient didn't take other medicine



Introduction way

Therapy Start date

Therapy Expiration date


/ /

/ /

/ /

/ /

/ /

/ /

/ /

/ /

/ /

/ /

Description НР:

HP start date:


Permission date:

____/___ /______

Whether it was accompanied MP cancellation by HP disappearance? o yes o no o PM wasn't cancelled by o unacceptably

Whether HP repetition after repeated purpose of PM is noted? o yes o no o PM repeatedly wasn't appointed by o unacceptably

Taken measures:

¨ Without treatment

¨ Cancellation of the suspected PM

¨ Decrease in a dose of the suspected PM

¨ Cancellation of accompanying treatment

¨ Medicinal therapy

¨ Non-drug therapy (including surgical intervention)

¨ Another to specify ___________________

Medicinal therapy of MP (if it was necessary)


¨ recovery without consequences

¨ state improvement

¨ state without changes

¨ recovery with consequences (to specify )_____________

¨ death

¨ unknown

¨ unacceptably

Criterion of gravity (note if it approaches):

¨ death

¨ life threat

¨ hospitalization or its extension

¨ clinically significant event (to specify)_____________

¨ congenital anomalies

¨ disability

¨ unacceptably

Significant additional information

Given clinical, laboratory, radiological trials and autopsy, including determination of concentration of MP in blood/fabrics if those are available and are connected with HP (please, give dates).

Accompanying diseases. The Anamnestichesky data, suspected medicinal interactions.

For congenital anomalies to specify all other MP accepted during pregnancy, and also date of the last periods. Please, attach additional pages if it is necessary.