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value="/bg/62-business-info/clinical-examinations-biz">- Клинични изпитвания</option> <option value="/bg/за-иал/други-комисии">- Комисии по етика</option> <option value="/bg/за-иал/други-комисии/67-cemi">- - ЕККИ - Етична комисия за клинични изпитвания</option> <option value="/bg/за-иал/други-комисии/189-архив">- - Архив</option> <option value="/bg/68-business-info/лекарствена-информация">- Лекарствена информация</option> <option value="/bg/69-business-info/лингвистична-проверка">- Лингвистична проверка</option> <option value="/bg/182-business-info/тест-за-ниво-на-разбираемост">- Тест за ниво на разбираемост</option> <option value="/bg/70-business-info/контрол-на-лекарствените-продукти">- Контрол на лекарствените продукти</option> <option value="/bg/75-business-info/pharmacopoeia-bg">- Фармакопея</option> <option value="/bg/187-business-info/cesp">- CESP</option> <option value="/bg/192-business-info/състрадателна-употреба">- Състрадателна употреба</option> <option value="/bg/инструкции-за-управляване-на-сигнали-при-верификация-и-отписване-на-лп-за-фирмите">- Инструкции за управляване на сигнали при верификация и отписване на лп - за фирмите</option> </select> </div></div></div></div><div id="sp-information-3" class="col-xs-12 col-sm-12 col-md-4"><div class="sp-column bda_information-3"><div class="sp-module "><h3 class="sp-module-title">ЗА МЕДИЦИНСКИТЕ СПЕЦИАЛИСТИ</h3><div class="sp-module-content"><select id="norr_dropdown" name="norr_dropdown" class = "inputbox" onchange = "if(this.value) window.location.href=this.value"> <option value="" selected="selected">Моля, изберете</option> <option value="/bg/съобщения">Съобщения</option> <option value="/bg/лекарства-за-медицинските-специалисти">Лекарства</option> <option value="/bg/лекарствена-безопасност-съобщения">Лекарствена безопасност</option> <option value="/bg/формуляр-за-съобщаване-на-нежелани-лекарствени-реакции-от-медицински-специалисти">- Формуляр за нежелани лекарствени реакции от медицински специалисти</option> <option value="/bg/лекарствена-безопасност-съобщения/методично-ръководство-за-реда-и-начина-на-съобщаване-на-подозирани-нлр-от-медицинските-специалисти">- Методично ръководство за реда и начина на съобщаване на подозирани НЛР от медицинските специалисти</option> <option value="/bg/лекарствена-безопасност-съобщения/съобщения-за-лекарствена-безопасност">- Съобщения за лекарствена безопасност</option> <option value="/bg/лекарствена-безопасност-съобщения/преки-съобщения-до-медицинските-специалисти">- Преки съобщения до медицинските специалисти</option> <option value="/bg/лекарствена-безопасност-съобщения/бюлетини-за-нежелани-лекарствени-реакции">- Бюлетини за Нежелани лекарствени реакции</option> <option value="/bg/лекарствена-безопасност-съобщения/архив-на-съобщенията-за-лекарствена-безопасност">- Архив на съобщенията за лекарствена безопасност</option> <option value="/bg/новорегистрирани-лекарствени-продукти-статии">Новорегистрирани лекарствени продукти</option> <option value="/bg/кръвни-продукти">Кръвни продукти</option> <option value="/bg/регистри">Регистри</option> <option value="/bg/програми-за-състрадателна-употреба-1">Програми за състрадателна употреба</option> <option value="/bg/инструкции-за-управляване-на-сигнали-при-верификация-и-отписване-на-лп">Инструкции за управляване на сигнали при верификация и отписване на лп </option> <option value="/bg/клинични-изпитвания-за-медицински-специалисти">Клинични изпитвания - за медицински специалисти</option> </select> </div></div></div></div></div></section><section id="sp-main-body"><div class="container"><div class="row"><div id="sp-component" class="col-sm-9 col-md-9"><div class="sp-column "><div id="system-message-container"> </div> <form method="post" id="YellowForm" class="bda" style="background: #ffffff none repeat scroll 0 0; border: 1px solid #006600; border-radius: 4px; margin: 0; padding: 10px 30px;" action="https://www.bda.bg/bg/%d1%84%d0%be%d1%80%d0%bc%d1%83%d0%bb%d1%8f%d1%80-%d0%b7%d0%b0-%d1%81%d1%8a%d0%be%d0%b1%d1%89%d0%b0%d0%b2%d0%b0%d0%bd%d0%b5-%d0%bd%d0%b0-%d0%bd%d0%b5%d0%b6%d0%b5%d0%bb%d0%b0%d0%bd%d0%b8-%d0%bb%d0%b5%d0%ba%d0%b0%d1%80%d1%81%d1%82%d0%b2%d0%b5%d0%bd%d0%b8-%d1%80%d0%b5%d0%b0%d0%ba%d1%86%d0%b8%d0%b8-%d0%be%d1%82-%d0%bd%d0%b5%d0%bc%d0%b5%d0%b4%d0%b8%d1%86%d0%b8%d0%bd%d1%81%d0%ba%d0%b8-%d0%bb%d0%b8%d1%86%d0%b0"><h2>ФОРМУЛЯР ЗА СЪОБЩАВАНЕ НА НЕЖЕЛАНИ ЛЕКАРСТВЕНИ РЕАКЦИИ ОТ НЕМЕДИЦИНСКИ ЛИЦА</h2> <div id="rsform_error_6" style="display: none;"><p class="formRed">(*) Задължително поле!</p></div>  <div class="formContainer form-horizontal" id="rsform_6_page_0"> <div class="row"> <div class="col-sm-12"> <div class="rsform-block rsform-block-remaindertext rsform-type-freetext"> <p class="message bda-justify">Информацията, която ще ни предоставите, е изключително важна за откриване на непознати нежелани реакции към лекарствените продукти, разрешени за употреба на територията на Р. България. Ще ни бъдат необходими Вашите данни за контакт с цел обратна връзка, за да потвърдим получаването на съобщението; ако се наложи да поискаме допълнителна информация, както и да Ви информираме за предприетите мерки. Уверяваме Ви, че личните данни на съобщителя/пациента се третират в съответствие със Закона за защита на личните данни. Изпълнителната агенция по лекарствата е регистрирана като администратор на лични данни. Удостоверение №0026870. Допълнителна информация може да прочетете <a href="https://www.adrreports.eu/docs/ADR_reporting_FINAL_BG.pdf" target="_blank"><span class="pdf">ТУК</span></a>.</p> <p class="error bda-justify">1. Моля, обърнете внимание, че някои полета, маркирани със звездичка (*), изискват задължително попълване, за да бъде прието съобщението Ви за валидно. Въпреки това ние Ви молим да попълните колкото е възможно повече данни, защото това е важно за оценката на съобщението Ви.</p> <p class="error bda-justify">2. Моля, обърнете внимание на полето <strong>Пациент (*)</strong> - в него се попълват САМО ИНИЦИАЛИТЕ му, евентуално разделени с точка! Пример: <em>И.С.П.</em>, ако искате да попълните данните за пациента Иван Стоянов Петров.</p> <p class="error bda-left"><strong class="formRequired">(*)</strong> Задължително поле!</p> </div> <div class="rsform-block rsform-block-messenger-data rsform-type-freetext"> <div class="WhiteForm col-xs-12 col-sm-12 col-md-12"><h4>Данни за съобщителя</h4></div> </div> <div class="form-group rsform-block rsform-block-messenger-type rsform-type-radiogroup"> <label class="col-sm-3 control-label formControlLabel" data-toggle="tooltip" title="" id="Messenger_type-grouplbl">Вие попълвате това съобщение в качеството на:<strong class="formRequired">(*)</strong></label> <div class="formControls col-sm-9" role="group" aria-labelledby="Messenger_type-grouplbl"> <label id="Messenger_type0-lbl" for="Messenger_type0" class="radio-inline"><input type="radio" name="form[Messenger_type]" value="Пациент (потребител)" id="Messenger_type0" class="rsform-radio" aria-required="true" />Пациент (потребител)</label><label id="Messenger_type1-lbl" for="Messenger_type1" class="radio-inline"><input type="radio" name="form[Messenger_type]" value=" Родител" id="Messenger_type1" class="rsform-radio" aria-required="true" /> Родител</label><label id="Messenger_type2-lbl" for="Messenger_type2" class="radio-inline"><input type="radio" name="form[Messenger_type]" value=" Друго немедицинско лице" id="Messenger_type2" class="rsform-radio" aria-required="true" /> Друго немедицинско лице</label> <span class="help-block formValidation"><span id="component254" class="formNoError">Моля, посочете като какъв попълвате тази форма.</span></span> </div> </div> <div class="form-group rsform-block rsform-block-messenger-name rsform-type-textbox"> <label class="col-sm-3 control-label formControlLabel" data-toggle="tooltip" title="Име и фамилия на лицето, даващо информацията." for="Messenger_Name">Име на съобщителя<strong class="formRequired">(*)</strong></label> <div class="formControls col-sm-9"> <input type="text" value="" size="60" placeholder=""Пример: Иван Петров"" name="form[Messenger_Name]" id="Messenger_Name" class="rsform-input-box form-control" aria-required="true" /> <span class="help-block formValidation"><span id="component247" class="formNoError">Моля, попълнете Вашето име и фамилия.</span></span> </div> </div> <div class="form-group rsform-block rsform-block-messenger-address rsform-type-textbox"> <label class="col-sm-3 control-label formControlLabel" data-toggle="tooltip" title="" for="Messenger_Address">Адрес</label> <div class="formControls col-sm-9"> <input type="text" value="" size="20" name="form[Messenger_Address]" id="Messenger_Address" class="rsform-input-box form-control" /> <span class="help-block formValidation"><span id="component249" class="formNoError"></span></span> </div> </div> <div class="form-group rsform-block rsform-block-messenger-phone rsform-type-textbox"> <label class="col-sm-3 control-label formControlLabel" data-toggle="tooltip" title="Въведете телефон (само цифри)." for="Messenger_Phone">Телефон<strong class="formRequired">(*)</strong></label> <div class="formControls col-sm-9"> <input type="text" value="" size="20" name="form[Messenger_Phone]" id="Messenger_Phone" placeholder="099999999999" class="rsform-input-box form-control" aria-required="true" /> <span class="help-block formValidation"><span id="component250" class="formNoError">Моля, въведете действителен телефонен номер.</span></span> </div> </div> <div class="form-group rsform-block rsform-block-messenger-email rsform-type-textbox"> <label class="col-sm-3 control-label formControlLabel" data-toggle="tooltip" title="Попълнете валиден и-мейл адрес или оставете празно това поле." for="Messenger_email">Електронна поща</label> <div class="formControls col-sm-9"> <input type="text" value="" size="20" name="form[Messenger_email]" id="Messenger_email" placeholder="Пример: your_mail@domain.com" class="rsform-input-box form-control" /> <span class="help-block formValidation"><span id="component255" class="formNoError">Невалиден и-мейл адрес.</span></span> </div> </div> <div class="rsform-block rsform-block-patient-data rsform-type-freetext"> <div class="WhiteForm col-xs-12 col-sm-12 col-md-12"><h4>Данни за пациента</h4></div> </div> <div class="form-group rsform-block rsform-block-patient rsform-type-textbox"> <label class="col-sm-3 control-label formControlLabel" data-toggle="tooltip" title="Въведете САМО инициалите на пациента (главни букви и точки). НЕ ИЗПОЛЗВАЙТЕ малки букви, запетайки, тирета и др. препинателни знаци и символи. Пример: И.С.П." for="Patient">Пациент<strong class="formRequired">(*)</strong></label> <div class="formControls col-sm-9"> <input type="text" value="" size="10" maxlength="10" name="form[Patient]" id="Patient" placeholder="САМО инициалите на пациента!" class="rsform-input-box form-control" aria-required="true" /> <span class="help-block formValidation"><span id="component182" class="formNoError">Моля, въведете САМО инициалите на пациента (главни букви и точки). НЕ ИЗПОЛЗВАЙТЕ малки букви, запетайки, тирета и др. препинателни знаци и символи. Пример: И.С.П.</span></span> </div> </div> <div class="form-group rsform-block rsform-block-age rsform-type-textbox"> <label class="col-sm-3 control-label formControlLabel" data-toggle="tooltip" title="Въведете възрастта на пациента (само цифри). Примери: 25 (за 25 годишен пациент); 0,11 (за 11-месечно бебе); 1,6 (за дете на година и половина) и др." for="Age">Възраст<strong class="formRequired">(*)</strong></label> <div class="formControls col-sm-9"> <input type="text" value="" size="5" maxlength="5" name="form[Age]" id="Age" class="rsform-input-box form-control" aria-required="true" /> <span class="help-block formValidation"><span id="component183" class="formNoError">Въведете възрастта на пациента (само цифри).</span></span> </div> </div> <div class="form-group rsform-block rsform-block-gender rsform-type-radiogroup"> <label class="col-sm-3 control-label formControlLabel" data-toggle="tooltip" title="" id="Gender-grouplbl">Пол<strong class="formRequired">(*)</strong></label> <div class="formControls col-sm-9" role="group" aria-labelledby="Gender-grouplbl"> <label id="Gender0-lbl" for="Gender0" class="radio-inline"><input type="radio" name="form[Gender]" value="мъжки" id="Gender0" class="rsform-radio" aria-required="true" />мъжки</label><label id="Gender1-lbl" for="Gender1" class="radio-inline"><input type="radio" name="form[Gender]" value="женски" id="Gender1" class="rsform-radio" aria-required="true" />женски</label> <span class="help-block formValidation"><span id="component184" class="formNoError">Укажете пола на пациента.</span></span> </div> </div> <div class="form-group rsform-block rsform-block-patient-weight rsform-type-textbox"> <label class="col-sm-3 control-label formControlLabel" data-toggle="tooltip" title="Въведете теглото на пациента в кг (само цифри и/или десетична точка; напр.: 79.5 за пациент, тежащ 79 кг и половина)." for="Patient_Weight">Тегло (кг)</label> <div class="formControls col-sm-9"> <input type="text" value="" size="5" name="form[Patient_Weight]" id="Patient_Weight" placeholder="Пример: 79.5 (за пациент с тегло 79 кг и половина)." class="rsform-input-box form-control" /> <span class="help-block formValidation"><span id="component257" class="formNoError">Въведете теглото на пациента в кг.</span></span> </div> </div> <div class="form-group rsform-block rsform-block-patient-stature rsform-type-textbox"> <label class="col-sm-3 control-label formControlLabel" data-toggle="tooltip" title="Въведете ръста на пациента в см (само цифри; напр.: 175 за пациент, висок 175 см)." for="Patient_Stature">Ръст (см)</label> <div class="formControls col-sm-9"> <input type="number" value="" size="3" min="30" step="1" name="form[Patient_Stature]" id="Patient_Stature" placeholder="Пример: 175 (за пациент, висок 175 см)." class="rsform-input-box form-control" /> <span class="help-block formValidation"><span id="component258" class="formNoError">Въведете ръста на пациента в см (само цифри).</span></span> </div> </div> <div class="rsform-block rsform-block-suspectedmedicinalproduct rsform-type-freetext"> <div class="WhiteForm col-xs-12 col-sm-12 col-md-12"><h4>Данни за подозираното лекарство</h4></div> </div> <div class="form-group rsform-block rsform-block-trade-mark rsform-type-textbox"> <label class="col-sm-3 control-label formControlLabel" data-toggle="tooltip" title="Търговко име на лекарствения продукт." for="Trade_Mark">Име на лекарствения продукт<strong class="formRequired">(*)</strong></label> <div class="formControls col-sm-9"> <input type="text" value="" size="20" name="form[Trade_Mark]" id="Trade_Mark" class="rsform-input-box form-control" aria-required="true" /> <span class="help-block formValidation"><span id="component260" class="formNoError">Моля, въведете търговското наименование на подозрителния лекарствен продукт.</span></span> </div> </div> <div class="form-group rsform-block rsform-block-formulation rsform-type-textbox"> <label class="col-sm-3 control-label formControlLabel" data-toggle="tooltip" title="Лекарствена форма: (напр. таблетки), количество (за таблетки от 250 милиграма)." for="Formulation">1. Лекарствена форма / дозова единица</label> <div class="formControls col-sm-9"> <input type="text" value="" size="20" name="form[Formulation]" id="Formulation" class="rsform-input-box form-control" /> <span class="help-block formValidation"><span id="component191" class="formNoError"></span></span> </div> </div> <div class="form-group rsform-block rsform-block-pharma-company rsform-type-textbox"> <label class="col-sm-3 control-label formControlLabel" data-toggle="tooltip" title="Фармацевтична компания - притежател на разрешението." for="Pharma_Company">2. Фармацевтична компания - притежател на разрешението</label> <div class="formControls col-sm-9"> <input type="text" value="" size="20" name="form[Pharma_Company]" id="Pharma_Company" class="rsform-input-box form-control" /> <span class="help-block formValidation"><span id="component200" class="formNoError"></span></span> </div> </div> <div class="form-group rsform-block rsform-block-part-no rsform-type-textbox"> <label class="col-sm-3 control-label formControlLabel" data-toggle="tooltip" title="Въведете партидния номер на опаковката." for="Part_No">3. Партиден номер</label> <div class="formControls col-sm-9"> <input type="text" value="" size="20" name="form[Part_No]" id="Part_No" class="rsform-input-box form-control" /> <span class="help-block formValidation"><span id="component202" class="formNoError"></span></span> </div> </div> <div class="form-group rsform-block rsform-block-prescription rsform-type-textbox"> <label class="col-sm-3 control-label formControlLabel" data-toggle="tooltip" title="За какво е предписано или препоръчано лекарството." for="Prescription">4. За какво е предписано/препоръчано лекарството?</label> <div class="formControls col-sm-9"> <input type="text" value="" size="20" name="form[Prescription]" id="Prescription" class="rsform-input-box form-control" /> <span class="help-block formValidation"><span id="component261" class="formNoError"></span></span> </div> </div> <div class="form-group rsform-block rsform-block-methodofadministration rsform-type-textbox"> <label class="col-sm-3 control-label formControlLabel" data-toggle="tooltip" title="Как приемахте лекарството? Кога, колко пъти и по колко на ден; на час? " for="MethodOfAdministration">5. Начин на приложение</label> <div class="formControls col-sm-9"> <input type="text" value="" size="20" name="form[MethodOfAdministration]" id="MethodOfAdministration" class="rsform-input-box form-control" /> <span class="help-block formValidation"><span id="component193" class="formNoError"></span></span> </div> </div> <div class="form-group rsform-block rsform-block-fromdate rsform-type-jquerycalendar"> <label class="col-sm-3 control-label formControlLabel" data-toggle="tooltip" title="Кога започнахте да прилагате лекарството?" for="txtjQcal6_2">6. Кога започнахте да прилагате лекарството?</label> <div class="formControls col-sm-9"> <div class="input-group"><input id="txtjQcal6_2" name="form[FromDate]" type="text" readonly="readonly" value="" class="rsform-calendar-box form-control" /><span class="input-group-btn"><button id="btnjQ6_2" type="button" class="btnCal rsform-calendar-button btn btn-default" onclick="RSFormPro.jQueryCalendar.showCalendar('6_2');">...</button></span></div><div id="caljQ6_2Container" style="clear:both;display:none;position:absolute;z-index:9979"></div><input id="hiddenjQcal6_2" type="hidden" name="hidden[6_FromDate]" value="" /> <span class="help-block formValidation"><span id="component187" class="formNoError"></span></span> </div> </div> <div class="form-group rsform-block rsform-block-todate rsform-type-jquerycalendar"> <label class="col-sm-3 control-label formControlLabel" data-toggle="tooltip" title="В случай на спиране на приема/приложението, кога за последно приехте лекарството?" for="txtjQcal6_1">7. Кога за последно приехте лекарството?</label> <div class="formControls col-sm-9"> <div class="input-group"><input id="txtjQcal6_1" name="form[ToDate]" type="text" readonly="readonly" value="" class="rsform-calendar-box form-control" /><span class="input-group-btn"><button id="btnjQ6_1" type="button" class="btnCal rsform-calendar-button btn btn-default" onclick="RSFormPro.jQueryCalendar.showCalendar('6_1');">...</button></span></div><div id="caljQ6_1Container" style="clear:both;display:none;position:absolute;z-index:9978"></div><input id="hiddenjQcal6_1" type="hidden" name="hidden[6_ToDate]" value="" /> <span class="help-block formValidation"><span id="component188" class="formNoError">Invalid Input</span></span> </div> </div> <div class="form-group rsform-block rsform-block-drug-cancellation rsform-type-checkboxgroup"> <label class="col-sm-3 control-label formControlLabel" data-toggle="tooltip" title="" id="Drug_Cancellation-grouplbl">Приемът</label> <div class="formControls col-sm-9" role="group" aria-labelledby="Drug_Cancellation-grouplbl"> <label id="Drug_Cancellation0-lbl" for="Drug_Cancellation0" class="checkbox-inline"><input type="checkbox" name="form[Drug_Cancellation][]" value="Приемът не е прекратяван" id="Drug_Cancellation0" class="rsform-checkbox" />не е прекратяван</label> <span class="help-block formValidation"><span id="component262" class="formNoError">Invalid Input</span></span> </div> </div> <div class="form-group rsform-block rsform-block-drug-more-info rsform-type-textarea"> <label class="col-sm-3 control-label formControlLabel" data-toggle="tooltip" title="Допълнителна информация относно лекарствения продукт в свободен текст." for="Drug_More_Info">8. Допълнителна информация за лекарствения продукт</label> <div class="formControls col-sm-9"> <textarea cols="50" rows="5" name="form[Drug_More_Info]" id="Drug_More_Info" class="rsform-text-box form-control"></textarea> <span class="help-block formValidation"><span id="component263" class="formNoError"></span></span> </div> </div> <div class="form-group rsform-block rsform-block-more-drugs rsform-type-textarea"> <label class="col-sm-3 control-label formControlLabel" data-toggle="tooltip" title="Моля, опишете всички други прилагани от Вас лекарства по времето на нежеланата реакция и до месец преди това, включително лекарства, закупени без рецепта или хранителни добавки." for="More_Drugs">9. Други прилагани от Вас лекарства по времето на нежеланата реакция</label> <div class="formControls col-sm-9"> <textarea cols="50" rows="5" name="form[More_Drugs]" id="More_Drugs" class="rsform-text-box form-control"></textarea> <span class="help-block formValidation"><span id="component264" class="formNoError"></span></span> </div> </div> <div class="rsform-block rsform-block-adversedrugreactions-data rsform-type-freetext"> <div class="WhiteForm col-xs-12 col-sm-12 col-md-12"><h4>Данни за подозираната нежелана лекарствена реакция</h4></div> </div> <div class="form-group rsform-block rsform-block-adversedrugreactions rsform-type-textarea"> <label class="col-sm-3 control-label formControlLabel" data-toggle="tooltip" title="Моля, опишете наблюдаваната нежелана лекарствена реакция на пациента." for="AdverseDrugReactions">Описание на реакцията<strong class="formRequired">(*)</strong></label> <div class="formControls col-sm-9"> <textarea cols="50" rows="5" name="form[AdverseDrugReactions]" id="AdverseDrugReactions" class="rsform-text-box form-control" aria-required="true"></textarea> <span class="help-block formValidation"><span id="component185" class="formNoError">Опишете кратко нежеланите лекарствени реакции.</span></span> </div> </div> <div class="form-group rsform-block rsform-block-adr-start-duration rsform-type-textarea"> <label class="col-sm-3 control-label formControlLabel" data-toggle="tooltip" title="Опишете кога започна и колко продължи нежеланата реакция?" for="ADR_Start_Duration">1. Кога започна и колко продължи нежеланата реакция? </label> <div class="formControls col-sm-9"> <textarea cols="50" rows="5" name="form[ADR_Start_Duration]" id="ADR_Start_Duration" class="rsform-text-box form-control"></textarea> <span class="help-block formValidation"><span id="component197" class="formNoError"></span></span> </div> </div> <div class="form-group rsform-block rsform-block-adr-precautions rsform-type-textarea"> <label class="col-sm-3 control-label formControlLabel" data-toggle="tooltip" title="Моля, опишете какви мерки бяха взети при лечението на реакцията." for="ADR_Precautions">2. Бяха ли предприети мерки за лечение на реакцията и какви?</label> <div class="formControls col-sm-9"> <textarea cols="50" rows="5" name="form[ADR_Precautions]" id="ADR_Precautions" class="rsform-text-box form-control"></textarea> <span class="help-block formValidation"><span id="component265" class="formNoError"></span></span> </div> </div> <div class="form-group rsform-block rsform-block-exit-of-adr rsform-type-checkboxgroup"> <label class="col-sm-3 control-label formControlLabel" data-toggle="tooltip" title="" id="Exit_of_ADR-grouplbl">3. Какъв е изходът от нежеланата реакция?</label> <div class="formControls col-sm-9" role="group" aria-labelledby="Exit_of_ADR-grouplbl"> <label id="Exit_of_ADR0-lbl" for="Exit_of_ADR0" class="checkbox-inline"><input type="checkbox" name="form[Exit_of_ADR][]" value="(възстановяване)" id="Exit_of_ADR0" class="rsform-checkbox" />възстановяване</label><label id="Exit_of_ADR1-lbl" for="Exit_of_ADR1" class="checkbox-inline"><input type="checkbox" name="form[Exit_of_ADR][]" value="(възстановяване с последствия)" id="Exit_of_ADR1" class="rsform-checkbox" />възстановяване с последствия</label><label id="Exit_of_ADR2-lbl" for="Exit_of_ADR2" class="checkbox-inline"><input type="checkbox" name="form[Exit_of_ADR][]" value="(възстановяването продължава)" id="Exit_of_ADR2" class="rsform-checkbox" />възстановяването продължава</label><label id="Exit_of_ADR3-lbl" for="Exit_of_ADR3" class="checkbox-inline"><input type="checkbox" name="form[Exit_of_ADR][]" value="(нежеланата лекарствена реакция продължава)" id="Exit_of_ADR3" class="rsform-checkbox" />нежеланата лекарствена реакция продължава</label><label id="Exit_of_ADR4-lbl" for="Exit_of_ADR4" class="checkbox-inline"><input type="checkbox" name="form[Exit_of_ADR][]" value="(нежеланата реакция е довела до смърт)" id="Exit_of_ADR4" class="rsform-checkbox" />нежеланата реакция е довела до смърт</label><label id="Exit_of_ADR5-lbl" for="Exit_of_ADR5" class="checkbox-inline"><input type="checkbox" name="form[Exit_of_ADR][]" value="(неизвестен)" id="Exit_of_ADR5" class="rsform-checkbox" />неизвестен</label><label id="Exit_of_ADR6-lbl" for="Exit_of_ADR6" class="checkbox-inline"><input type="checkbox" name="form[Exit_of_ADR][]" value="(друг)" id="Exit_of_ADR6" class="rsform-checkbox" />друг</label> <span class="help-block formValidation"><span id="component240" class="formNoError">Invalid Input</span></span> </div> </div> <div class="form-group rsform-block rsform-block-adr-led-to rsform-type-checkboxgroup"> <label class="col-sm-3 control-label formControlLabel" data-toggle="tooltip" title="Моля, опишете доколко и как нежеланата реакция повлия на ежедневните Ви дейности." id="ADR_Led_To-grouplbl">4. Доколко нежеланата реакция повлия на ежедневните Ви дейности?</label> <div class="formControls col-sm-9" role="group" aria-labelledby="ADR_Led_To-grouplbl"> <label id="ADR_Led_To0-lbl" for="ADR_Led_To0" class="checkbox-inline"><input type="checkbox" name="form[ADR_Led_To][]" value="(предизвика леко неудобство)" id="ADR_Led_To0" class="rsform-checkbox" />предизвика леко неудобство</label><label id="ADR_Led_To1-lbl" for="ADR_Led_To1" class="checkbox-inline"><input type="checkbox" name="form[ADR_Led_To][]" value="(причини неработоспособност)" id="ADR_Led_To1" class="rsform-checkbox" />причини неработоспособност</label><label id="ADR_Led_To2-lbl" for="ADR_Led_To2" class="checkbox-inline"><input type="checkbox" name="form[ADR_Led_To][]" value="(доведе до приемане в болница)" id="ADR_Led_To2" class="rsform-checkbox" />доведе до приемане в болница</label><label id="ADR_Led_To3-lbl" for="ADR_Led_To3" class="checkbox-inline"><input type="checkbox" name="form[ADR_Led_To][]" value="(наложи животоспасяващи действия)" id="ADR_Led_To3" class="rsform-checkbox" />наложи животоспасяващи действия</label><label id="ADR_Led_To4-lbl" for="ADR_Led_To4" class="checkbox-inline"><input type="checkbox" name="form[ADR_Led_To][]" value="(причини инвалидност)" id="ADR_Led_To4" class="rsform-checkbox" />причини инвалидност</label><label id="ADR_Led_To5-lbl" for="ADR_Led_To5" class="checkbox-inline"><input type="checkbox" name="form[ADR_Led_To][]" value="(друго)" id="ADR_Led_To5" class="rsform-checkbox" />друго</label> <span class="help-block formValidation"><span id="component239" class="formNoError">Invalid Input</span></span> </div> </div> <div class="form-group rsform-block rsform-block-adr-reason rsform-type-textarea"> <label class="col-sm-3 control-label formControlLabel" data-toggle="tooltip" title="Допускате ли, че наблюдаваната нежелана лекарствена реакция е възникнала в резултат на неумишлена грешка при предписването, отпускането в аптеката, приготвянето или приложението на лекарствения продукт и ако е така, моля, обяснете." for="ADR_Reason">5. Възможна причина за нежеланата лекарствена реакция</label> <div class="formControls col-sm-9"> <textarea cols="50" rows="5" name="form[ADR_Reason]" id="ADR_Reason" placeholder="Допускате ли, че наблюдаваната нежелана лекарствена реакция е възникнала в резултат на неумишлена грешка при предписването, отпускането в аптеката, приготвянето или приложението на лекарствения продукт и ако е така, моля, обяснете." class="rsform-text-box form-control"></textarea> <span class="help-block formValidation"><span id="component245" class="formNoError"></span></span> </div> </div> <div class="form-group rsform-block rsform-block-adr-comment rsform-type-textarea"> <label class="col-sm-3 control-label formControlLabel" data-toggle="tooltip" title="Моля, добавете допълнителна информация, която може да бъде от значение - резултати от изследвания, други заболявания, алергии, тютюнопушене, злоупотреба с лекарствени продукти, алкохол, наркотици, бременност, кърмене и др." for="ADR_Comment">6. Моля, добавете допълнителна информация</label> <div class="formControls col-sm-9"> <textarea cols="50" rows="5" name="form[ADR_Comment]" id="ADR_Comment" placeholder="Моля, добавете допълнителна информация, която може да бъде от значение - резултати от изследвания, други заболявания, алергии, тютюнопушене, злоупотреба с лекарствени продукти, алкохол, наркотици, бременност, кърмене и др." class="rsform-text-box form-control"></textarea> <span class="help-block formValidation"><span id="component242" class="formNoError"></span></span> </div> </div> <div class="form-group rsform-block rsform-block-your-doctor-contact rsform-type-textarea"> <label class="col-sm-3 control-label formControlLabel" data-toggle="tooltip" title="Ако сте съгласни да потърсим допълнителна информация по този случай от Вашия лекуващ лекар, моля, напишете данни за връзка с него. " for="Your_Doctor_Contact">7. Данни за Вашия лекуващ лекар</label> <div class="formControls col-sm-9"> <textarea cols="50" rows="5" name="form[Your_Doctor_Contact]" id="Your_Doctor_Contact" placeholder="Ако сте съгласни да потърсим допълнителна информация по този случай от Вашия лекуващ лекар, моля, напишете данни за връзка с него." class="rsform-text-box form-control"></textarea> <span class="help-block formValidation"><span id="component266" class="formNoError"></span></span> </div> </div> <div class="form-group rsform-block rsform-block-date rsform-type-jquerycalendar"> <label class="col-sm-3 control-label formControlLabel" data-toggle="tooltip" title="Дата на подаване на информацията." for="txtjQcal6_0">Дата<strong class="formRequired">(*)</strong></label> <div class="formControls col-sm-9"> <div class="input-group"><input id="txtjQcal6_0" name="form[Date]" type="text" value="" placeholder="dd/mm/yyyy" class="rsform-calendar-box form-control" aria-required="true" /><span class="input-group-btn"><button id="btnjQ6_0" type="button" placeholder="dd/mm/yyyy" class="btnCal rsform-calendar-button btn btn-default" onclick="RSFormPro.jQueryCalendar.showCalendar('6_0');">...</button></span></div><div id="caljQ6_0Container" style="clear:both;display:none;position:absolute;z-index:9965"></div><input id="hiddenjQcal6_0" type="hidden" name="hidden[6_Date]" value="" /> <span class="help-block formValidation"><span id="component268" class="formNoError"></span></span> </div> </div> <div class="form-group rsform-block rsform-block-recaptcha rsform-type-captcha"> <label class="col-sm-3 control-label formControlLabel" data-toggle="tooltip" title="Анти-спам код. Въведете генерираните символи; ако не ги разчитате добре, генерирайте отново с помощта на бутона." for="captchaTxt252">Анти-спам<strong class="formRequired">(*)</strong></label> <div class="formControls col-sm-9"> <div class="row"> <div class="col-md-3 text-center"> <img src="data:image/png;base64,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" id="captcha252" alt="Анти-спам" /> </div> <div class="col-md-9"> <div class="input-group"> <input type="text" value="" name="form[ReCaptcha]" id="captchaTxt252" class="rsform-captcha-box form-control" aria-required="true" /> <span class="input-group-btn"> <a href="javascript:void(0)" class="rsform-captcha-refresh-button btn btn-default" onclick="RSFormPro.refreshCaptcha('252', '/bg/формуляр-за-съобщаване-на-нежелани-лекарствени-реакции-от-немедицински-лица?task=captcha&componentId=252&format=image'); return false;">🔁.</a> </span> </div> </div> </div> <span class="help-block formValidation"><span id="component252" class="formNoError">Невалидни символи! 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