Adverse Reaction Report Home Adverse Reaction Report Step 1 of 4 25 % Information about the patient, who experienced the adverse reactionThis report applies to* myself a / my child other person as follows other person as follows:* Initials* Birth date or age* Gender* female male divers Country and Postal code (please enter the first 3 digits) Height Weight * Mandatory field Information about the product of URSAPHARM, from which the adverse reaction is suspectedName of the product (also strength/company, e.g. Zinkorotat-POS, 40mg)*Batch number Reason for use (e.g. blepharitis, vitamin deficiency) Dose (e.g. 20mg twice per day) Type of administration (e.g. into the mouth, to the eyes) Start of administration DD slash MM slash YYYY Stop of administration DD slash MM slash YYYY Are you still taking/using the product? * Mandatory field Information about the product of URSAPHARM, from which the adverse reaction is suspectedDate of initial occurrence of adverse reactions DD slash MM slash YYYY Description of reactions / symptoms (e.g. skin rash, itching, fever etc.)* Estimate the severity* mild moderate severe Characterise "severe" further* life-threatening persistent disability inpatient treatment required fatal other other* How is your/the condition, in relation to the adverse reaction, now? completely recovered improvement of the reactions ongoing other other* Did the reactions / symptoms resolve after withdrawal of the product? yes no no information available Did the reactions / symptoms repeat after re-administration of the same product? yes no no information available Was there a pregnancy while using the product? yes no Additional information, e.g. administration of other medication at the same time, previous known drug reactions, known allergies or intolerances, other present diseases, available results from laboratory tests etc.* Mandatory field Contact detailsoptional (e.g. in case of queries)Name* Address Phone number or email address* Qualification* Healthcare professional Consumer, patient or other non healthcare professional By submitting the form you confirm to accept our privacy policy.* Mandatory field