Reazioni avverse Regione Autonoma della Sardegna Azienda Sanitaria Locale N°2 Servizio di Farmaco-Economia e Farmaco-Vigilanza Farmaco*** Tipo di reazione*** j Data*** ____________________ _______________________ LIBRETTO FARMACEUTICO ________ ____________________ _______________________ ________ ____________________ _______________________ ________ ____________________ _______________________ ________ ____________________ _______________________ ________ ____________________ _______________________ ________ ____________________ _______________________ ________ ____________________ _______________________ ________ ____________________ _______________________ ________ ____________________ _______________________ ________ Assistito:_________________________________________ (cognome e nome) Codice fiscale: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Data di nascita: _ _ / _ _ / _ _ _ _ Telefono: _ _ _ _ / _ _ _ _ _ _ _ Medico Curante: __________________________________ Telefono: _ _ _ _ /_ _ _ _ _ _ _ Cellulare: _ _ _ _ /_ _ _ _ _ _ hai un effetto indesiderato da farmaco ? _________________________________ (cognome e nome) Segnalalo Telefono: _ _ _ _/_ _ _ _ _ _ _ _ _ _ al tuo Medico al tuo Farmacista al Servizio di farmacovigilanza della tua ASL Presidio S. Giovanni di Dio 2° piano, Viale Aldo Moro, Olbia Tel: 0789552638 / Fax 0789552246 Email: [email protected], Campagna di sensibilizzazione anno 2012 Farmaco* Scadenza* Data visita medico** 01 __________________________ _________ _________ 02 __________________________ _________ 03 __________________________ Scadenza* Data visita medico** 21 __________________________ _________ _________ _________ 22 __________________________ _________ _________ _________ _________ 23 __________________________ _________ _________ 04 __________________________ _________ _________ 24 __________________________ _________ _________ 05 __________________________ _________ _________ 25 __________________________ _________ _________ 06 __________________________ _________ _________ 26 __________________________ _________ _________ 07 __________________________ _________ _________ 27 __________________________ _________ _________ 08 __________________________ _________ _________ 28 __________________________ _________ _________ 09 __________________________ _________ _________ 29 __________________________ _________ _________ 10 __________________________ _________ _________ 30 __________________________ _________ _________ 11 __________________________ _________ _________ 31 __________________________ _________ _________ 12 __________________________ _________ _________ 32 __________________________ _________ _________ 13 __________________________ _________ _________ 33 __________________________ _________ _________ 14 __________________________ _________ _________ 34 __________________________ _________ _________ 15 __________________________ _________ _________ 35 __________________________ _________ _________ 16 __________________________ _________ _________ 36 __________________________ _________ _________ 17 __________________________ _________ _________ 37 __________________________ _________ _________ 18 __________________________ _________ _________ 38 __________________________ _________ _________ 19 __________________________ _________ _________ 39 __________________________ _________ _________ 20 __________________________ _________ _________ 40 __________________________ _________ _________ * Indicare il farmaco presente nel proprio domicilio e la relativa scadenza. ** Indicare la data di visita dal proprio medico. **** Indicare il farmaco e il tipo di reazione determinata dallo stesso e la data dell’evento. Farmaco*
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