CONSUMER REPORTING FORM

We are sorry that you or someone that you know has had a reaction to the medicine they were taking. Information you provide when you report adverse drug reaction (side effect) can improve the safe use of medicines. Please provide your contact details below so we can follow up for further information about your report if necessary. You can report on side effects, drug ineffectiveness, product quality, suspected counterfeit or medical device defect, medication error (i.e. mistake made in the prescription, dosing, dispensing or administration of the medicine).
REPORTER DETAILS - About you the person making the report
First Name
 
Second Name
Telephone
 
Email
Town / City
 
Region
WHO EXPERIENCED THE SIDE EFFECT ?
WHO ?
 
Name or Initials
 
Gender
Age at time of the side effect
 
Weight (kg)
SIDE EFFECT
Please complete as many fields as possible.
What were the signs of the suspected side efffect?
 
When did the side effect start?
When did the side effect stop?
 
Have you the reporter or the person who experienced the side effect:
Please select if the side effect resulted in any of tbe following:
 
Please Specify
 
Do you think this reaction occurred as a result of a mistake made in the prescription, dosing, dispensing or administration of the medication?
MEDICINE DETAILS – About the medicine which might have caused the side effect
Suspected Medicine
 
Dosage:
Batch Number
 
Manufacturer
Expiry Date
 
Date drug was started
Date you stopped taking the drug
 
What form did you take your medicine?
What was/were the reason(s) for taking the suspected medicine? (Indication)
Where was medicine obtained?
 
What action was taken with this medicine as a result of the side effect(s)
Were you taking any other medicine or herbal products prior to the side effect?
Name of Medicine
 
Dosage
Date Started
 
Date Ended
Reasons for use
 
Other information you think might be important, including any other medical condition, any allergies that the person may have, results of any tests performed etc.
If we need further information to help us understand the case do we have your permission to contact you?
Please send e-mail to the National Pharmacovigilance Centre at drug.safety@fdaghana.gov.gh, or call 0244 310 297 for any further assistance regarding drug safety issues.