Merz - Adverse Event Form

I. EVENT INFORMATION

1. Patient Initials (first, last) *

1a. Country *

2. Date of Birth *

2a. Age

3. Sex *

Female

Male

4-6. Reaction Onset *

7-13. Describe Reactions *

Indicate All Propriate To Adverse Event *

Patient died

Involved or prolonged hospitalisation

Involved persistent or significant disability or incapacity

Life threathening

Congenital anomaly

Other medical important condition

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II. SUSPECT DRUG(S) INFORMATION

15. Daily Dose(s) *

14. Suspect Drug(s) *

Det her er en beskrivelse på et felt

16. Route(s) of Administration *

17. Indication(s) For Use *

18. Therapy Date (from) *

18. Therapy Date (to) *

19. Theraphy Duration *

20. Did Reaction Abate After Stopping Drug? *

YES

NO

UK

NA

21. Did Reaction Reappear After Reintroduction? *

Yes

No

UK

NA

III. CONCOMITANT DRUG(S) AND HISTORY

22. Concomitant Drug(s) and Dates of Administration *

*Exclude those used to treat reaction

23. Other Relevant History *

IV. MANUFACTURER INFORMATION

24a. Name and Address of The Company Managing Case

24b. Original Report Number

24c. Date of Receipt

24d. Date of this Report

25a. Report Type

Initial

Follow-up

26. Name and Address of Reporter (Include Zip Code)

Reporter Email