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NOTIFIER
Last name and first name
Fax
Email
Specialty
Phone
Address
PATIENT
PATIENT
Initials
Size
Date of birth
Weight
OR AGE
Sex
Male
Female
NOTIFIER
MEDICAL BACKGROUND / ALLERGIES / TABACCO / ALCOHOL
MEDICAL BACKGROUND / ALLERGIES / TABACCO / ALCOHOL
Tobacco
Yes
No
Alcohol
Yes
No
Quantity (Current)
Quantity (Current)
End Date
End Date
Allergy
Yes
No
Specify
Medical background
PATIENT
DRUG CONCERNED
DRUG CONCERNED
Medicine
Way
N° Lot
Period
Dose per intake and frequency
Indication(s)
Has the patient already been treated with the medication?
Yes
No
Unknown
MEDICAL BACKGROUND / ALLERGIES / TABACCO / ALCOHOL
THERAPEUTIC DECISION
THERAPEUTIC DECISION
Stopping the drug
Decrease in dosage
Symptomatic treatment
Any
Unknown
Specify other therapeutic decision
Has the adverse effect improved after stop / decrease in the drugs of the medicinal product?
Yes
No
Unknown
If the drug was stopped, was it reintroduced?
Yes
No
Unknown
If so, has the adverse effect reappeared?
Yes
No
Unknown
SUSPECT DRUGS
Other suspect drugs
Oui
Non
Drug
Dose per intake and frequency
Way
Period
Indication(s)
ASSOCIATED MEDICINES
Associated medicines
Yes
No
Drug
Dose per intake and frequency
Way
Period
Indication(s)
TREATMENT OF ADVERSE REACTION
Treatment of adverse reaction
Yes
No
Drug
Dose per intake and frequency
Way
Period
Indication(s)
DRUG CONCERNED
UNWANTED EVENT(S)
UNWANTED EVENT(S)
Alternative Etiology :
Date of occurrence
Healing Date
Time of appearance
Period
Gravity criterion
Death :
Hospitalization
Extension of hospitalization
Disability / Inability
Vital prognosis committed
Congenital anomaly
Medically significant
Serious judgment
Not serious
Medication Relation / undesirable effect
Likely
Possible
Probably unbound
No relation
Evolution
Healing
Improvement
In progress
Healing with sequelae
Death
Unknown
Description - clinical evolution
BIOLOGICAL TESTS
Biological tests
Yes
No
Date / Hour
Test
Results
Units
Normals
ADDITIONAL TESTS
Additional tests
Yes
No
Date
Reviews
Results / Comments
THERAPEUTIC DECISION
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