Biofarma Natural CMD

Pharmacovigilance is a responsibility shared by physicians, the pharmaceutical industry, health authorities and patients.
Pharmacovigilance has been implemented by the need to evaluate the use, effects and safety of medicines once they have been marketed.

Data from the patient or user of the product

Name

Birth date 31/DIC/1999

Gender M / F

Diagnosis of the patient or because of the administration

Weight Kg.

Height Mts.

Address:

Zip Code:

City

State

Home phone

Office phone

Other phone

E-mail

If you feel any discomfort or adverse reaction to taking one of the products we suggest you fill in the fields requested in the questionnaire to continue your case. Together with the council we will analyze your case and you will receive a response.

Details on suspicion of causing the reaction product

Date of reaction Start

End

Date start treatment Start

End

Description of the suspect RAM

Continuing discomfort? Yes No

The presenting signs and symptoms which were tolerated Yes No

Need any drug treatment Yes No

Required hospitalization Yes No If so how long it lasted

The reaction interfered with their normal life Yes No

The reaction caused any persistent or significant disability Yes No

We also suggest, if you have any problems with the completion of this questionnaire please contact to the Call Center, they will support the capture of data. Phone 01800 28 80 CMD (263)

Details on suspected reaction caused by the product

In the case of pregnant women

The reaction caused deformities or abnormalities in the newborn Yes No

In case of death

The reaction directly or indirectly contributed to the death of the patient Yes No

Was left to administer the drug suspect Yes No

RAM disappeared after discontinuation of medication Yes No

Lowering the dose? Yes No If so, how much?

Pharmacotherapy will change? Yes No If so, which?

Reaction reappear when you return to take the medicine? Yes No

If you do not withdraw the drug persists reaction? Yes No

Suspect drug information

Name

Generic name

Lab producer

Lot No

Expiration date

Dose

Administration

Therapeutic Indication

Reason for prescription

Consequence of the event is called?

Classification of drug was used on the recommendation of:

Recipes Farmacy Family Other

Concomitant therapy

Medicine	Dose	Administration	Start	End	Reason for prescription

Important facts of clinical history

Diagnosis:

Allergies:

Pregnancy Yes No If yes, time

Surgery was performed

Laboratory data

NOTIFIER DETAILS

Name * Required

DS_PROFESSION * Required

Address: * Required

Zip Code: * Required

City * Required

State * Required

Phone * Required

E-mail * Required