Suspected adverse reaction report

Administrative details

Your first name and family name:*

Gender:* female male

E-mail:*

Telephone number:

Drug/medical device information

Brand Name:*---AcidofolanAmbrosan 30 mg // Ambrosan retarded release capsules // Ambrosan drops // Ambrosan syrupAmilia 50 mg tablets // Amilia 200 mg tablets // Amilia 400 mg coated tabletsArtrilom 15 mgAudiclean Ear cleaning solutionAudiclean Ear DropsCifloxinalCifloxinal 500 mgCombiso 2.5 mg/6.25 mg//Combiso 5 mg/6.25 mg//Combiso 10 mg/6.25 mgCorsim 10
Corsim 20
Corsim 40DefluoxDolgit 800Dolgit creamDolgit gelFamosan 10 mgFamosan 20 mg // Famosan 40 mgFluconazole PMCS 100 mgGodasal 100Godasal 500IndapItoprid PMCS 50 mgKofein KLadymarinLawarin 2 // Lawarin 5Loseprazol 10 mgLoseprazol 20 mgLoseprazol 20 mgLoseprazol 40 mgMeteospasmylMigränertonMonosan 20 mg // Monosan 40 mgMyogit 25 mgMyogit 50Nitresan 10 mg//Nitresan 20 mgOstokalPerindopril PMCS 4 mg // Perindopril PMCS 8 mgPhysiomer BabyPhysiomer EucalyptusPhysiomer Gentle Jet & SprayPhysiomer KidsPhysiomer Nasal Decongestant - HypertonicPhysiomer UnidosesProkanazolPromagsanPropanorm 150 mgPropanorm 300 mgPropanorm 35 mg / 10 ml injection solutionProsulpin 200 mgProsulpin 50 mgProtradonProtradon 100 mg tabletsProtradon dropsProvirsanRanisan 150 mgRanisan 75 mgRivocor 5 // Rivocor 10Rivodaron 200Rybí olejSelzink PlusSpasmed 30Spasmed 5 // Spasmed 15Terfimed 250Tiaprid PMCS 100 mgUrsosanVital BuchuVital Melasa

Detailed product information:Please, quote a dosage form & strength, daily dose, therapy dates (from-to), batch number and concomitant medicinal products and/or food supplements

Adverse reaction information

Please, describe the adverse reaction you have experienced as excactly as possible:*

Country of occurrence:*---AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua And BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarussiaBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicCocos (Keeling) IslandsColombiaComorosCongoCongo, The Democratic Republic Of TheCook IslandsCosta RicaCote D'ivoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHeard Island And Mcdonald IslandsHoly See (Vatican City State)HondurasHong KongHungaryChadChileChinaChristmas IslandIcelandIndiaIndonesiaIran, Islamic Republic OfIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKirgiziaKiribatiKorea, Democratic People's Republic OfKorea, Republic OfKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyan Arab JamabiriyaLiechtensteinLithuaniaLuxembourgMacauMacedonia, The Former Yugoslav Republic OfMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia, Federated States OfMoldaviaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinian Territory, OccupiedPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint HelenaSaint Kitts And NevisSaint LuciaSaint Pierre And MiquelonSaint Vincent And The GrenadinesSamoaSan MarinoSao Tome And PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovak RepublicSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia And The South Sandwich IslandsSpainSri LankaSudanSurinameSvalbard And Jan MayenSwazilandSwedenSwitzerlandSyrian Arab RepublicTaiwan, Province Of ChinaTajikistanTanzania, United Republic OfThailandTogoTokelauTongaTrinidad And TobagoTunisiaTurkeyTurkmenistanTurkmenistanTurks And Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis And FutunaWestern SararaYemenYugoslaviaZambiaZimbabwe

Physician contact details

Please, quote contact details of the physician, who treated your adverse reaction (name/address/telephone number/e-mail):

*mandatory information