Close
Skip to content
Search for:
About Us
Company History
Licenses and certificates
Products
Pharmaceutical Products and API
Health and safety
Partners
Newsroom
Careers
Contacts
Search for:
About Us
Company History
Licenses and certificates
Products
Pharmaceutical Products and API
Health and safety
Partners
Newsroom
Careers
Contacts
About Us
Company History
Licenses and certificates
Products
Pharmaceutical Products and API
Health and safety
Partners
Newsroom
Careers
Contacts
Questionnaire for medical professionals
Home
/
Medicines safety
/
Questionnaire for medical professionals
Questionnaire for medical professionals
Test Admin
2019-03-04T13:04:10+03:00
Step 1 of 4 - Step 1
0%
Problem Description
Describe your problem
*
I registered an adverse reaction after using the medicine;
I noted the lack of efficacy of the medicine;
I discovered a counterfeit medicine;
I need advice on drug interactions when taking the medicine(s) produced by Samson-Med LLC in combination with any other medicines;
I need advice in connection with the method of use of the medicine, not described in the instructions for medical use;
I need advice on overdose;
Contact Information
Name
*
First
Last
Position
*
i.e. nurse, or physician
Phone
*
Email
*
Enter Email
Confirm Email
Country
City or town
Patient Information
Name of a patient
First
Last
Date of birth
*
Date Format: DD slash MM slash YYYY
Gender
Male
Female
Main diagnosis
Accompanying illnesses
Complications
Body mass, kg
*
Body height, cm
*
Phone of a patient
Email of a patient
Country
Details of Adverse Reaction to the Medicine
Medicine
*
Canned medical bile
Chymopsin
Chymotrypsin
Cytochrome C
Lydase
Ribonuclease
Samprost®
Thymalin®
Trypsin crystallisatum
Series
*
Valid until
*
Date Format: MM slash DD slash YYYY
end of shelf life from the package
How the medicine was used by the patient?
*
Route of administration, dose, course duration
Starting date of the medicine use
*
Date Format: DD slash MM slash YYYY
Ending date of the medicine use
*
Date Format: DD slash MM slash YYYY
Date of registration of the first symptoms of an adverse reaction
Date Format: DD slash MM slash YYYY
Date of relief of undesirable reaction
Date Format: DD slash MM slash YYYY
Where did you bought the medicine?
Unwanted reaction has developed:
*
When the patient was in the hospital
During home treatment as prescribed by a doctor
With self-medication (without the supervision of the attending physician)
The outcome of the reaction:
*
Full recovery
Partial recovery (stopping or reduction of symptoms)
No change
Transition of the disease to the chronic form
Death
Other
What was the other outcome of the reaction?
Describe in detail all the manifestations of an undesirable reaction.
Measures taken
Measures taken to reduce unwanted reactions
*
Changing the dosage regimen of the medicine
Complete abolition of the medicine
Substitution for a medicine of the same pharmaceutical group
Replacement for a completely similar medicine, but from another manufacturer
For stopping the reaction, forced emergency measures were taken.
For stopping the reaction, the patient took other drugs (analgesics, antispasmodics, anti-inflammatory drugs, etc.)
Hospitalization in hospital was required for stopping the reaction
Previous experience with the medicine
Experience of taking the drug before the development of an undesirable reaction.
The medicine was used for the first time
The drug was used previously, no adverse reactions were noted
The drug was used previously, there were similar adverse reactions.
Is it possible to provide for examination samples of the drug that caused the adverse reaction?
Yes
No
Consent
Add files
Drop files here or
Accepted file types: jpg, jpeg, png, pdf, gif, bmp.
You can add up to 4 files. Please use JPG and PDF for images and documents.
Data Use Consent
*
I hereby give my consent to receive, process, store and transfer my (and my patient) personal data to the authorized state bodies of the Ministry of Health of Russian Federation and Roszdravnadzor
Comments
This field is for validation purposes and should be left unchanged.
Go to Top