ConSERF

CONSUMER SIDE EFFECT REPORTING FORM / BORANG PELAPORAN KESAN SAMPINGAN UBAT UNTUK PENGGUNA

NATIONAL CENTRE FOR ADVERSE DRUG REACTIONS MONITORING / PUSAT PEMONITORAN KESAN ADVERS UBAT KEBANGSAAN

ConSERF Form / Borang ConSERF

Person Information / Maklumat Peribadi

Please fill in all sections marked with * and give as much other information as you can. / Sila isi semua bahagian bertanda * dan bekalkan seberapa banyak maklumat tambahan yang boleh.

All personal data will remain confidential. / Semua maklumat peribadi akan dirahsiakan.

Name / Nama:
Sex / Jantina:
Age / Umur: *
Age Unit / Unit Umur: *
Nationality / Warganegara:
Ethnicity / Bangsa:
Date of Report / Tarikh Pelaporan:
Tel. Number / No. Telefon: *
Email Address / Alamat e-mel: *

Any health problem / allergies / pregnancy ? (Please specify) / Ada masalah kesihatan/ alahan/ mengandung? (Sila nyatakan) *

Medication Information / Maklumat Ubat

Medicine Name / Nama ubat yang disyaki :

(Include MAL number if known / Nyatakan nombor MAL jika diketahui)

Dosage / Dos:

(eg. 250mg three times daily / cth. 250mg tiga kali sehari)

Date Started / Tarikh ubat dimulakan:
Date Stopped / Tarikh ubat dihentikan:
Reason for use / Kegunaan ubat:

Medicine Name /
Nama Ubat
Dosage /
Dos
Date Started /
Tarikh Ubat Dimulakan
Date Stopped /
Tarikh Ubat Dihentikan
Reason for use /
Kegunaan Ubat
Action /
Tindakan
*Were any other medicines taken at the same time? / *Adakah sebarang ubat lain yang diambil pada tempoh masa yang sama?

Other Medicine Taken
Medicine Name:

(Include MAL number if known)

Dosage:

(eg. 250mg three times daily)

Date Started:
Date Stopped:
Reason for use:

Medicine Name
Dosage
Date Started
Date Stopped
Reason for use
Action

Side Effect Information / Maklumat Berkenaan Kesan Sampingan Ubat

Date of side effect / Tarikh kesan sampingan: * Reaction started on / Kesan sampingan bermula pada:

Reaction subsided on / Kesan sampingan sembuh pada:

Please describe the side effects experiences / Sila terangkan kesan sampingan yang dialami: *

How long was the medications taken before the side effect appeared?
/ Berapa lamakah ubat yang disyaki telah diambil sebelum kesan sampingan bermula? *
Did the side effect subside when the medications was stopped?
/ Adakah kesan sampingan berkurangan apabila berhenti mengambil ubat? *
Did the side effect reappear when the medication was taken again?
/ Adakah kesan sampingan muncul kembali apabila ubat diambil semula? *
How serious was the side effect? / Apakah tahap serius kesan sampingan ini? *
Was any treatment given / medication taken to overcome the side effect?
/ Adakah sebarang rawatan diberi/ubat diambiI untuk mengatasi kesan sampingan ini? *
What is the current outcome of the side effect? / Apakah kesudahan kesan sampingan ini? *


I confirm that / Saya mengesahkan bahawa

  • All the information and attachment provided is true and complete. / Kesemua maklumat dan lampiran yang dimasukkan adalah benar dan lengkap.