NATIONAL CENTRE FOR ADVERSE DRUG REACTIONS MONITORING
Please fill in all sections marked with * and give as much other information as you can.
All personal data will remain confidential.
Any health problem / allergies ? (Please specify) *
(Include MAL number if known)
(eg. 250mg three times daily)
Side Effect Information
Please describe the side effects experiences: *
I confirm that
Help us make medicines safer
If you think you have a side effect to your medicine, please seek advice from your pharmacist or doctor.
Every report will be analysed and entered into the Malaysian and World Health Organisation (WHO) databases of medication side effects
Please complete as many sections as possible to ensure your report is useful and provide your contact details to allow us to obtain further information about your report if necessary
Questions or comments?
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