ࡱ> ')$%&:;z#` bjbjmm ]Q%$"^ ^ ^ ^  d2Q2Q2Q8jQFTj&fUzfff giT!DZ$uwwwwww$hx *~i"i"**^ ^ f gr&ȣȣȣ*^ f> Rfuȣ*uȣȣ0 @ "fZU  2Q$\x&\ğ\H\ ~"ȣ̗^~~~~~~&****jjjN/!jjjN/ $  ^ ^ ^ ^ ^ ^   Rapport confidentiel de ractions indsirables aux mdicaments& Date du rapport (dd/mm/yy) :  FORMTEXT   / FORMTEXT   / FORMTEXT      Remarques: Un rapport est seulement valable si au moins une donne du patient, un mdicament suspect et un effet indsirable sont mentionns. A ct des champs de texte libres vous avez aussi des champs avec des listes de slection. A ct de chaque possibilit de slection se trouve un code pour usage interne. 1. Rapporteur (Veuillez remplir au moins les donnes marques avec une astrisque* ) Nom* :  FORMTEXT       Prnom :  FORMTEXT       Titre :  FORMTEXT       Profession :  FORMDROPDOWN  Numro INAMI :  FORMTEXT       Rue + n + bote :  FORMTEXT       Code postal:  FORMTEXT       Commune/ville :  FORMTEXT       Tl :  FORMTEXT       Fax :  FORMTEXT       E-mail* :  FORMTEXT       2. Patient Initiales :  FORMTEXT       Date de naissance :  FORMTEXT   / FORMTEXT   / FORMTEXT      ou ge :  FORMTEXT      FORMDROPDOWN  Sexe :  FORMDROPDOWN  Poids (en kg) :  FORMTEXT       S il s agit d une raction indsirable survenue dans le cadre d une tude clinique, veuillez complter les donnes suivantes aussi : Numro du patient dans l tude :  FORMTEXT       Nom de l tude :  FORMTEXT        3. Ractions indsirables3.1. Symptme(s) et/ou diagnostic : 1.  FORMTEXT       2.  FORMTEXT       3.  FORMTEXT       4.  FORMTEXT       5.  FORMTEXT       6.  FORMTEXT      Date de dbut et de fin (dd/mm/yyyy) :  FORMTEXT   / FORMTEXT   / FORMTEXT      -  FORMTEXT   / FORMTEXT   / FORMTEXT      ou dure de la raction indsirable :  FORMTEXT        FORMDROPDOWN  Evolution de la raction indsirable  FORMDROPDOWN :  FORMDROPDOWN  Information complmentaire concernant la raction indsirable :  FORMTEXT      3.2. Gravit de la raction indsirable : Ci-dessous, vous trouvez les critres de gravit d une raction indsirable grave. Selon vous, la raction indsirable est-elle grave?  FORMDROPDOWN  Si oui, pour quelle(s) raison(s) ? Il sagit dune raction indsirable ayant ncessit une hospitalisation  FORMDROPDOWN  Il sagit dune raction indsirable ayant mis la vie en danger  FORMDROPDOWN  Il sagit dune raction indsirable fatale  FORMDROPDOWN  Il sagit dune raction indsirable ayant entran une squelle permanente  FORMDROPDOWN  Il sagit dune raction indsirable associe un vnement mdical important  FORMDROPDOWN  Dans ce cas, prcisez lequel :  FORMTEXT       Si le rapport concerne l administration d un mdicament pendant la grossesse, s agit-il d une raction indsirable ayant entran une anomalie congnitale?  FORMDROPDOWN 3.3. Avez-vous rapport la raction indsirable au titulaire de lenregistrement?  FORMDROPDOWN 3.4. Rsultat(s) des tests de laboratoire et/ou des examens mdicaux relatif(s) la raction indsirable (ex. hpatite : exclure une infection virale) Nature du test ou de lexamen Date du test ou de lexamenRsultat ou information complmentaire1.  FORMTEXT       2.  FORMTEXT       3.  FORMTEXT       4.  FORMTEXT       5.  FORMTEXT       FORMTEXT   / FORMTEXT   / FORMTEXT       FORMTEXT   / FORMTEXT   / FORMTEXT       FORMTEXT   / FORMTEXT   / FORMTEXT       FORMTEXT   / FORMTEXT   / FORMTEXT       FORMTEXT   / FORMTEXT   / FORMTEXT      FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT      Disposez-vous d autres donnes (mdicales) complmentaires que vous n avez pas t en mesure de mentionner ci-dessus (rapport d hospitalisation, rapport d examen, & )?  FORMTEXT      ggggg 4. Mdicament(s) suspect(s)Mdicament 1Mdicament 2Mdicament 3Mdicament Nom de spcialit ou principe(s) actif(s) (si le nom de spcialit n est pas connu) Forme galnique (ex. comprims,& )   FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT      Posologie : p.e. 30 mg 3 fois par 1 jour FORMTEXT        FORMDROPDOWN ;  FORMTEXT     fois par  FORMTEXT 1  FORMDROPDOWN   FORMTEXT        FORMDROPDOWN   FORMTEXT       FORMTEXT        FORMDROPDOWN ;  FORMTEXT     fois par  FORMTEXT 1  FORMDROPDOWN   FORMTEXT        FORMDROPDOWN  FORMTEXT       FORMTEXT        FORMDROPDOWN ;  FORMTEXT     fois par  FORMTEXT 1  FORMDROPDOWN   FORMTEXT        FORMDROPDOWN   FORMTEXT       ou description : Voie d administration : Si pas mentionne dans la liste :Dure du traitement :Date de dbut et de fin (dd/mm/yyyy) ou dure du traitement       " $ & . 0 2 wdwQw%jh CJU^JmH sH %jh CJU^JmH sH &jh CJU^JmHnHsH u%jh CJU^JmH sH h CJ^Jh 5CJ\^Jjh CJU^JmH sH h CJ^Jh 5CJ \^J.h 5B*CJ \^Jehphr%h 5CJ\^Jehr2 J ) dtrbkd$$IfF+,0,64 FaV (<$If$If7$8$H$ p#$<<a$ ^H2 J % & ( ) 1 2 < = 4 6 J L N X Z ~ ȸkTk*CJOJQJ^JaJmH sH  0 2 F H J T V 46Jܶt\ܶIܶܶ%jh CJOJQJUaJ.jh CJOJQJUaJmHnHsHu-j\h CJOJQJUaJmHsH-jLh CJOJQJUaJmHsH'jh CJOJQJUaJmHsHh CJOJQJaJmH sH *jh CJOJQJUaJmHnHujh CJOJQJUaJ%jh CJOJQJUaJJLNXZ .02<>`tvܶܶܶ{ܶhܶ{ܶUܶ{ܶ%jh CJOJQJUaJ%j~h CJOJQJUaJ"h CJOJQJ^JaJmH sH +h 5>*CJOJQJ\^JaJmH sH %jh CJOJQJUaJh CJOJQJaJmH sH *jh CJOJQJUaJmHnHujh CJOJQJUaJ%jnh CJOJQJUaJ  "6ܶzczKz7'jh CJOJQJU^JmH sH .jh CJOJQJU^JmHnHsHu-jqh CJOJQJU^JmHsH'jh CJOJQJU^JmHsHh CJOJQJ^JmH sH h mH sH h CJOJQJ^JmH sH h CJOJQJaJmH sH *jh CJOJQJUaJmHnHujh CJOJQJUaJ%j^h CJOJQJUaJ68:>@BDXZ\`bdfz|~ԼԬԬԼԬԬ~ԼԬԬgԼԬԬPԬ-jG h CJOJQJU^JmH sH -j h CJOJQJU^JmH sH -j/ h CJOJQJU^JmH sH -j h CJOJQJU^JmH sH h CJOJQJ^JmH sH .jh CJOJQJU^JmHnHsH u'jh CJOJQJU^JmH sH -j h CJOJQJU^JmH sH <>RTV`bdpۭp\E\-j h CJOJQJU^JmHsH'jh CJOJQJU^JmHsH$h 5CJOJQJ\^JmH sH "h CJOJQJ^JaJmH sH .jh CJOJQJU^JmHnHsH u-jW h CJOJQJU^JmH sH -ji h CJOJQJU^JmH sH h CJOJQJ^JmH sH 'jh CJOJQJU^JmH sH dpnpzL<kd$$IfF4+,,64 FaVf4$If]kd$$IfF+,0,64 FaV($If (<$IfDFZ\^hjlpzĭěs`N@h CJ^JaJmH sH #jh CJU^JaJmHsH%h 5CJOJQJ^JaJmH sH h CJ^JmH sH h mH sH &h CJOJPJQJ^JaJmH sH "h CJOJQJ^JaJmH sH -joh CJOJQJU^JmHsHh CJOJQJ^JmH sH 'jh CJOJQJU^JmHsH.jh CJOJQJU^JmHnHsHu.b2\> p#($If^` ($If^` ($If^`  *,:<PRT^`npدءدءwدءbدءM)j:h CJU^JaJmHsH)jh CJU^JaJmHsH)jh CJU^JaJmHsH)jh CJU^JaJmHsHh CJ^JaJmH sH %h 5CJOJQJ^JaJmH sH *jh CJU^JaJmHnHsHu#jh CJU^JaJmHsH)jh CJU^JaJmHsH   "$.02x~طśzgSzz@%jh CJU^JmH sH &jh CJU^JmHnHsH u%jZh CJU^JmH sH h CJ^Jjh CJU^JmH sH h 5CJ\ h 5CJ)jh CJU^JaJmHsHh CJ^JaJmH sH %h 5CJOJQJ^JaJmH sH #jh CJU^JaJmHsH*jh CJU^JaJmHnHsHu (*,0246JLNVX\rԮԛԈ܂{p{g{h 5CJ\h 5CJ^JaJ h 5CJ h CJ%j,h CJU^JmH sH %jh CJU^JmH sH %jh CJU^JmH sH %j~h CJU^JmH sH h CJ^Jjh CJU^JmH sH &jh CJU^JmHnHsH u$JLhjlprº|o|[Kh CJOJQJ^JmH sH 'jh CJOJQJU^JmHsHh 5CJaJmH sH .jh 5CJOJQJU^JaJmHsH%h 5CJOJQJ^JaJmH sH %jFh CJU^JmH sH h CJ^Jjh CJU^JmH sH jh CJUmHnHujh CJU h CJjh CJU,.0:<>@ZıԎw_QE4!h CJOJQJ\^JmH sH h CJ^JmH sH h CJ^JaJmH sH .jh CJOJQJU^JmHnHsHu-jh CJOJQJU^JmHsHh CJOJQJ^JmHsH%h 5CJOJQJ^JaJmH sH $h 5CJOJQJ\^JmH sH h CJOJQJ^JmH sH 'jh CJOJQJU^JmHsH-jh CJOJQJU^JmHsH>@f:`kd$$IfF+,0,64 FaV ($If^`Qkd$$IfF40 +  ,64 FaVf4*PQSTbcd&()789:fghʷܔq\qqGqq(jh CJOJQJU\^J(jh CJOJQJU\^J"jh CJOJQJU\^J!h CJOJQJ\^JmH sH %j(h CJOJQJU^Jjh CJOJQJU^J%h 5CJOJQJ^JaJmH sH "h CJOJQJ^JaJmH sH h CJOJQJ^JmH sH %h CJOJQJ\^JaJmH sH :} ;<fekd"$$IfF4+,0,64 FaVf4 ($If ($If^` ($If^` hvwx`dfzfzOf-j!h CJOJQJU^JmHsH'jh CJOJQJU^JmHsHh CJOJQJ^JmH sH (j h CJOJQJU\^J(jh CJOJQJU\^J%h CJOJQJ\^JaJmH sH "jh CJOJQJU\^J(jh CJOJQJU\^J!h CJOJQJ\^JmH sH  )*89:<IJĠ{jU{@{j(h 5CJOJQJ\^JaJmH sH (j"h CJOJQJU\^J!h CJOJQJ\^JmH sH "jh CJOJQJU\^J%h CJOJQJ\^JaJmH sH "h CJOJQJ^JaJmH sH "h CJOJQJ^JaJmH sH h CJOJQJ^JmH sH 'jh CJOJQJU^JmHsH.jh CJOJQJU^JmHnHsHu DE ǿpWp;W7j'h 5CJOJQJU\^JaJmHsH1jh 5CJOJQJU\^JaJmHsH(h 5CJOJQJ\^JaJmHsH(h 5>*CJOJQJ^JaJmH sH (h 5>*CJOJQJ^JaJmH sH h OJQJ^JaJmH sH h mH sH "h CJOJQJ^JaJmH sH "jh CJOJQJU\^J(j#h CJOJQJU\^J  DE-fkd9%$$IfF4+, t0,64 FaVf4 $If$If`kd$$$IfF+,0,64 FaVEd < j dZZZZZ $Ifkd%$$IfF4F +  t0,6    4 FaVf4$If $$Ifa$    * , . 8 : < B D X Z \ f h j p r ʻʦʻʦnʻʦRʻʦ7j(h 5CJOJQJU\^JaJmHsH7j (h 5CJOJQJU\^JaJmHsH7j'h 5CJOJQJU\^JaJmHsH(h 5CJOJQJ\^JaJmHsHh 5CJ\aJmHsH1jh 5CJOJQJU\^JaJmHsH8jh 5CJOJQJU\^JaJmHnHsHu ʭʞv]C1v"h CJOJQJ^JaJmHsH2jh CJOJQJU^JaJmHnHsH u1j)h CJOJQJU^JaJmH sH "h CJOJQJ^JaJmH sH +jh CJOJQJU^JaJmH sH h 5CJ\aJmH sH 8jh 5CJOJQJU\^JaJmHnHsHu1jh 5CJOJQJU\^JaJmHsH7j)h 5CJOJQJU\^JaJmHsH !!!! 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FORMDROPDOWN   FORMDROPDOWN   FORMDROPDOWN Si une nouvelle administration du mdicament a eu lieu, la raction indsirable est-elle rapparue?   FORMDROPDOWN   FORMDROPDOWN   FORMDROPDOWN  5. Autre(s) mdicament(s) administr(s) (* nom de spcialit ou principe(s) actif(s)) Mdicaments* 1.  FORMTEXT       2.  FORMTEXT       3.  FORMTEXT       4.  FORMTEXT       5.  FORMTEXT       6.  FORMTEXT       Posologie  FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT       Voie d administration  FORMDROPDOWN   FORMDROPDOWN   FORMDROPDOWN   FORMDROPDOWN   FORMDROPDOWN   FORMDROPDOWN Administration: date de dbut ou de fin ou dure du traitement  FORMTEXT   / FORMTEXT   / FORMTEXT     -  FORMTEXT   / FORMTEXT   / FORMTEXT      ou  FORMTEXT        FORMDROPDOWN   FORMTEXT   / FORMTEXT   / FORMTEXT     -  FORMTEXT   / FORMTEXT   / FORMTEXT      ou  FORMTEXT        FORMDROPDOWN   FORMTEXT   / FORMTEXT   / FORMTEXT     -  FORMTEXT   / FORMTEXT   / FORMTEXT      ou  FORMTEXT        FORMDROPDOWN   FORMTEXT   / FORMTEXT   / FORMTEXT     -  FORMTEXT   / FORMTEXT   / FORMTEXT      ou  FORMTEXT        FORMDROPDOWN   FORMTEXT   / FORMTEXT   / FORMTEXT     -  FORMTEXT   / FORMTEXT   / FORMTEXT      ou  FORMTEXT        FORMDROPDOWN   FORMTEXT   / FORMTEXT   / FORMTEXT     -  FORMTEXT   / FORMTEXT   / FORMTEXT      ou  FORMTEXT        FORMDROPDOWN  Indication  FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT       6. Donnes mdicales du patient (ventuellement) Veuillez mentionner ici d autres donnes mdicales importantes (comme grossesse, allergies, maladies & ). Donne mdicaleDate de dbut et/ou de fin Description//information complmentaire1.  FORMTEXT       FORMTEXT   / FORMTEXT   / FORMTEXT      -  FORMTEXT   / FORMTEXT   / FORMTEXT      FORMTEXT      2.  FORMTEXT       FORMTEXT   / FORMTEXT   / FORMTEXT      -  FORMTEXT   / FORMTEXT   / FORMTEXT      FORMTEXT      3.  FORMTEXT       FORMTEXT   / FORMTEXT   / FORMTEXT      -  FORMTEXT   / FORMTEXT   / FORMTEXT      FORMTEXT      4.  FORMTEXT       FORMTEXT   / FORMTEXT   / FORMTEXT      -  FORMTEXT   / FORMTEXT   / FORMTEXT      FORMTEXT      5.  FORMTEXT       FORMTEXT   / FORMTEXT   / FORMTEXT      -  FORMTEXT   / FORMTEXT   / FORMTEXT      FORMTEXT      6.  FORMTEXT       FORMTEXT   / FORMTEXT   / FORMTEXT      -  FORMTEXT   / FORMTEXT   / FORMTEXT      FORMTEXT       7. Donnes complmentaires concernant le rapport Si d autres informations importantes n ont pas trouv place ci-dessus dans le formulaire, veuillez les mentionner ici. Vous pouvez galement utiliser cette rubrique pour communiquer vos questions spcifiques, remarques ou suggestions relatives ce rapport.  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