Report a side effect

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1. About you

I am reporting as Patient or consumer (a patient, family member or carer) Healthcare professional

Choose how you are reporting.

Your name or initials

Enter your name or initials.

Which country do you live or work in?

Choose a country.

Email address or phone number (at least one) We need this to check your report and, if necessary, ask follow-up questions.

Email address

Phone number

Enter an email address or a phone number.

2. The patient

Please fill in at least one of the following: age, sex or initials. Age helps us to see whether a problem mainly affects certain age groups.

Age

Age (number)

Age unit

Sex

Patient’s initials

Fill in at least one: age, sex or initials.

3. The medicine

Which Amarox medicine was used? Write the name as shown on the packaging, for example “Clopidogrel Amarox 75 mg”. Not sure? Write what you know.

Enter the name of the medicine, or what you know about it.

Batch number Printed on the box or blister after “Batch” or “Lot”. If you do not know it, leave it blank.

Other medicines taken at the time Write “None” if the patient took no other medicines, or “Don’t know”.

Tell us about other medicines, or write “None”.

More about the medicine (optional)

Dose and how it was taken

Start date

Stop date (if stopped)

What was it used for?

4. The side effect

What happened? Please describe the side effect as precisely as you can.

Describe what happened.

When did the side effect start?

How is the patient now?

Did the side effect lead to any of the following?

Relevant medical history and test results Write “None” if there is nothing relevant, or “Don’t know”.

Tell us about relevant medical history or test results, or write “None”.

More about the side effect (optional)

In which country did the side effect happen?

What was done with the medicine after the side effect started?

Anything else we should know? (optional)

Pregnancy or breastfeeding The patient was pregnant when the medicine was used The patient was breastfeeding

Something may have gone wrong when using the medicine (for example a wrong dose, a mix-up or taking too much) There is a problem with the product itself (for example damaged packaging)

5. Documents (optional)

Attach documents For example a hospital or doctor’s letter, test results or photos. Accepted file types: PDF, JPG or PNG only. Up to 5 files. Each file must be smaller than 1 MB. Please only attach what is relevant.

6. Privacy and sending

We use the details you give to assess the safety of our medicines, as the law requires. They are stored securely, handled confidentially and passed on to the medicines authorities in a way that follows European rules on masking personal data. We do not use them for marketing.

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Thank you for your report

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We will contact you if we need more information. If you feel unwell, please contact your doctor.