Information about all adverse effects of Sintez JSC medicines can be forwarded to the authorized person for pharmacovigilance as follows: Fill in the online "Adverse Drug Reaction" notification form. Call us in Moscow 8 (495) 137-57-27 Ext. 1048; and/or in Kurgan 8 (3522) 48-14-48. Send an e-mail message to: farmnadzor@kurgansintez.ru. Send a fax to: (3522) 48-12-33 marked "Pharmacovigilance" Send information by regular mail: building 7, Prospekt Konstitutsii, the city of Kurgan, 640008 or building 10a, Bolshoy Savvinsky pereulok, Moscow, 119435 (marked "Pharmacovigilance")


PHYSICIAN or other person informing about ADR

Full name and age:
Job title and place of employment:
Phone:
Email:
Treatment:
Message:
Date:

Information about patient

Initials:
Ambulatory card or case history No. :
Sex:
Age:
Pregnancy:
Compromised liver function:
Compromised kidney function:
Allergy (specify):

DRUG that allegedly caused ADR

International nonproprietary name (INN):
Trade name (TN):
Manufacturer:
Country:
Series number:
Indication for administration:
Route of administration:
One-time/daily dose:
Therapy start date:
Therapy end date:
ARD detection date:
Dose that caused ADR:
OTHER DRUGS
taken within the last 3 months,
including drugs taken by the patient himself (at own discretion)
The patient did not take other drugs:
INN:
TN:
Route of administration:
Therapy start date:
Therapy end date:
Indication:
INN:
TN:
Route of administration:
Therapy start date:
Therapy end date:
Indication:
INN:
TN:
Route of administration:
Therapy start date:
Therapy end date:
Indication:
INN:
TN:
Route of administration:
Therapy start date:
Therapy end date:
Indication:
INN:
TN:
Route of administration:
Therapy start date:
Therapy end date:
Indication:
INN:
TN:
Route of administration:
Therapy start date:
Therapy end date:
Indication:
ADR description:
ADR start date:
Drug application date:
Whether drug dechallenge was accompanied by disappearance of ADR:
Whether there was repeated ADR after drug rechallenge:
Measures taken:
Other measure taken:
Outcome:
Other outcome:
Additional important information: Additional information may include:
– Data of clinical, laboratory, radiological investigations and autopsy, including determination of drug concentration in blood/tissues, if any and if associated with ADR (please specify dates)
– Concurrent diseases.
– Medical history data, suspect drug interactions
– For congenital abnormalities please specify all other drugs taken during pregnancy, and also the date of the recent menstruation.