ConSERF

CONSUMER SIDE EFFECT REPORTING FORM

NATIONAL CENTRE FOR ADVERSE DRUG REACTIONS MONITORING

ConSERF Form

Person Information

Please fill in all sections marked with * and give as much other information as you can.

All personal data will remain confidential.

Name:
Sex:
Age: *
Nationality:
Ethnicity:
Date of Report:
Tel. Number: *
Email Address:

Any health problem / allergies ? (Please specify) *

Medication Information

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
*Were any other medicines taken at the same time?

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

Date of side effect: * Reaction started on:

Reaction subsided on:

Please describe the side effects experiences: *

How long was the medications taken before the side effect appeared? *
Did the side effect subside when the medications was stopped? *
Did the side effect reappear when the medication was taken again? *
How serious was the side effect? *
Was any treatment given / medication taken to overcome the side effect? *
What is the current outcome of the side effect? *


I confirm that

  • All the information and attachment provided is true and complete.