Ph lc 5

BO CO PHN NG C HI CA THUC

Ni bo co:

THNG TIN V NGI BO CO, BNH NHN V N V BO CO

S C BO MT

M s bo co ca n v:
M s bo co (do Trung tm quc gia qun l):
..

Xin anh/ch hy bo co k c khi khng chc chn v sn phm gy ra phn ng v/hoc khng c y cc thng tin
A. THNG TIN V BNH NHN
2. Ngy sinh:.../.../

1. H v tn:........................................

Hoc tui:.........

4. Cn nng:

3. Gii tnh

Nam

....kg

B. THNG TIN V PHN NG C HI (ADR)

6. Phn ng xut hin sau bao lu (tnh t ln dng cui cng ca

5. Ngy xut hin phn ng:..../.../..

thuc nghi ng):

8. Cc xt nghim lin quan n phn ng

7. M t biu hin ADR

9. Tin s (d ng, thai nghn, nghin thuc l, nghin ru, bnh

gan, bnh thn)

10. Cch x tr phn ng

11. Mc nghim trng ca phn ng

T vong
Nhp vin/Ko di thi gian nm vin
D tt thai nhi
e da tnh mng
Tn tt vnh vin/nng n
Khng nghim trng
12. Kt qu sau khi x tr phn ng
T vong do ADR
Cha hi phc
Hi phc c di chng
Khng r
T vong khng lin quan n thuc
ang hi phc
Hi phc khng c di chng
C. THNG TIN V THUC NGHI NG GY ADR
S
T
T

13.Thuc (tn gc v

tn thng mi)

Dng
bo ch,
hm
lng

Nh
sn xut

S l

Liu
dng
mt ln

S ln
dng
trong
ngy/
tun/
thng.

Ngy iu tr
(Ngy/thng/nm)

ng
dng

Bt u

L do dng thuc

Kt thc

i
ii
iii
iv
STT
(Tng
ng 13.)

14.Sau khi ngng/gim liu ca thuc b nghi ng, phn ng c

15.Ti s dng thuc b nghi ng c xut hin li phn ng

c ci thin khng?
C
Khng
Khng ngng/gim liu

khng?
C
Khng

Khng c thng tin

Khng ti s dng

Khng c thng tin

i
ii
iii
iv
16. Cc thuc dng ng thi (Ngoi tr cc thuc dng iu tr/ khc phc hu qu ca ADR)
Tn thuc

Dng bo ch,
hm lng

Ngy iu tr (ngy/thng/nm)
Bt u
Kt thc

D. PHN THM NH ADR CA N V

Tn thuc

Dng bo ch,
hm lng

Ngy iu tr (ngy/thng/nm)
Bt u
Kt thc

17. nh gi mi lin quan gia thuc v ADR

Chc chn
C kh nng
C th

Khng chc chn

Cha phn loi
Khng th phn loi

Khc :.
..
..

18. n v thm nh ADR theo thang no?

Thang WHO

Thang Naranjo

Thang khc:

19. Phn bnh lun ca cn b y t (nu c)

E. THNG TIN V NGI BO CO

20. H v tn:..........................................
Ngh nghip/Chc v:
in thoi lin lc:
Email:.
21. Ch k
23. Ngy bo co:/../
22. Dng bo co:
Ln u/
B sung

Xin chn thnh cm n!

HNG DN LM BO CO
Xin hy bo co tt c cc phn ng c
hi m anh/ch nghi ng, c bit khi:

Cc phn ng lin quan ti thuc mi

Cc phn ng khng mong mun

hoc cha c bit n

Cc phn ng nghim trng

Tng tc thuc

Tht bi trong iu tr

Cc vn v cht lng thuc

Cc sai st trong qu trnh s dng

thuc.

Cch bo co:

in thng tin vo mu bo co
Ch cn in nhng phn anh/ch c thng tin
C th nh km thm mt vi trang (nu mu bo co khng khong trng
in thng tin hay c nhng xt nghim lin quan).
Xin hy gi bo co v Trung tm Quc gia v Thng tin thuc v Theo di phn
ng c hi ca thuc theo cc a ch sau:
Th: Trung tm Quc gia v Thng tin thuc v Theo di phn ng
c hi ca thuc
Trng i hc Dc H Ni
13-15 L Thnh Tng, Qun Hon Kim, H Ni

Mu bo co ny c p dng cho cc
phn ng gy ra bi:

Thuc v cc ch phm sinh hc

Vc xin

Cc thuc c truyn hoc thuc c

ngun gc dc liu

Thc phm chc nng.

Ngi bo co c th l:

Bc s

Dc s

Nha s

Y t/ iu dng/n h sinh

Cc nh cung cp dch v chm sc

sc khe khc.

Fax: 04.3.9335642

in thoi: 04.3.9335618
Website: http://canhgiacduoc.org.vn
Email: di.pvcenter@gmail.com

Anh/ch c th ly mu bo co ny ti khoa Dc, phng K hoch tng

hp ca bnh vin hoc ti t trang web http://canhgiacduoc.org.vn. Nu c bt
k thc mc no, anh/ch c th lin h vi Trung tm Quc gia v Thng tin
thuc v Theo di phn ng c hi ca thuc theo s in thoi 043 933 5618
hoc theo a ch email di.pvcenter@gmail.com.

Phn dnh cho Trung tm DI & ADR Quc gia

1.

Gi xc nhn ti n v bo co

3.

Phn ng c trong y vn/ SPC/ CSDL

2.

7.

Phn loi phn ng

Thuc mi
Thuc c
Nghim trng
Khng nghim trng
Mc nghim trng ca phn ng

4.

Nhp d liu vo h c s d liu quc gia

6.

Nhp d liu vo phn mm Vigiflow

e da tnh mng/ gy t vong

8.

Nhp vin/ ko di thi gian nm vin

Gi bo co ti hi ng thm nh

10. Kt qu thm nh
Chc chn
C kh nng
C th

Ngy gi
..../.../.
Khng chc chn
Cha phn loi
Khng th phn loi

11. Ngi qun l bo co

Gy d tt/ tn tt

9.

Lin quan ti lm dng/ ph thuc thuc

Gi bo co cho UMC

Ngy gi
...../.../...

Khc:

13. Ch k
12. Ngy:../../..