ADR Report – Gilvasan GmbH

Reporter Data

Name, surname (or initial) *

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Email *

Telephone *

Product name, strength and pharmaceutical form *

Adverse Drug Reaction description *

ADR starting date *

ADR ending date

Has the patient been hospitalizedYesNo

Doctors (name, surname or initial)

Status of the patient at the moment

Medical product details

Batch details (if known)

Purpose of the use of medicinal product

Medicinal product usage starting date

Medicinal product usage ending date

Are you still using the medicinal product?YesNo

Treatment discontinuedYesNo

Are you using any other medicinal product?YesNo

In case of yes product name, strength, pharmaceutical form

Patient initial *

Age *

Gender *malefemaleother

Weight (kg)

Height (cm)