JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
REPORT OF SUSPECTED ADVERSE REACTIONS TO MEDICINES
REGISTRATION OF THE DEPARTMENT OF PHARMACOVIGILANCE OF LABORATORIES VIDES
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Notifier name
*
Your answer
Profession or occupation
Your answer
Are you the person taking the medicine?
*
Yes
No
If your answer was no, please indicate the name of the person who is taking it
Your answer
Relationship
Your answer
Contact phone number
Your answer
Contact E-Mail
Your answer
Age or age range
*
Your answer
Pregnancy
*
Yes
No
If your answer was Yes in the previous question, detail how many weeks
Your answer
Are you breastfeeding
Yes
No
Clear selection
Suspect drug name
*
Your answer
Manufacturing Laboratory
*
Your answer
Lot Number
Your answer
Expiration Date
MM
/
DD
/
YYYY
Dose
Your answer
Administration way
*
Your answer
Reason for use
*
Your answer
Frequency of consumption
First time
I had already consumed it before
It is part of your daily medication
Clear selection
Detail the adverse reaction presented
*
Your answer
Reaction start date
MM
/
DD
/
YYYY
Reaction end date
MM
/
DD
/
YYYY
Indicate what you did when you noticed the possible adverse reaction
Stopped the medication
Reduced the dose
Changed medication
Continuous with treatment
It was single dose
Clear selection
Based on the above, please indicate whether
The reaction disappeared
The reaction subsided
The reaction continued
Clear selection
Hospitalization required?
Yes
No
Clear selection
Mention what other medications you take and the reason for use
Your answer
Mention if you have any known allergies. Which?
Your answer
You authorize the Laboratorios Vides pharmacovigilance team to contact you in the event of requiring further information
*
Yes
No
I accept terms and conditions
*
Yes
No
Additional comments (if any)
Your answer
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms
