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Farmacovigilância na Bluemed
Notificação de reação adversa
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Patient ID
Name Initials
Sex
Female
Male
Weight
Height
Age
Evolution of the patient
Recovery
Recovery with sequels
In recovery
No recovery
Death possibly related to the reaction
Death unrelated to the reaction
Other
Identity of the notifier
Name of the notifier
Profession
Speciality
Workplace
E-mail
Phone
Characterization of Adverse Reaction
Description
Treatment
Start Date
End Date
Adverse effects
Death
Inability
Risk of life
Prolonged inpatient
Genetic Damage
Suspect drug
Trade name
Lot
Dose
Route
Indication
Start Date
End Date
Characterization
Suspension of the drug
The reaction improved after discontinuation
The reaction was maintained after discontinuation
The product was re-introduced
The reaction was repeated after reintroduction
Previous reactions are known to the drug
Reactions with other drugs
Causal relationship
Certain/Sure
Probable
Plausible
Unlikely