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SUSPECTED ADVERSE REACTION REPORT FORM

The purpose of this form is to enable you to record for CARM (Centre for Adverse Reaction Monitoring) and the Ministry of Health what you believe was an adverse reaction to a prescription medicine that you as a patient experienced. 

The need for this form has arisen because in recent TV documentaries, newspaper and magazine articles, and radio talk-back programmes  it has become apparent that adverse reactions to drugs are being under-reported in New Zealand.

Health Canada is reported (Toronto Star, Dec.4, 2004, H Section: "A drugged nation") as estimating that "fewer than 1 in 10 cases are ever reported". There is no reason to believe that the New Zealand situation is different.

New Zealand, like Canada, has no legal requirement for prescribers of drugs to report patients' adverse reactions. The Centre for Adverse Reactions Monitoring in New Zealand (CARM) has a form on its website for prescribers of drugs. It is unlikely that in a 15 minute consultation with a patient, time will be found to complete such a form.

This form therefore enables the patients themselves (consumers) to participate in compiling a more accurate picture so that knowledge can be established of how well a drug appears to be being tolerated. Proper reporting of possible adverse reactions enables better monitoring of the effects of medicines in common usage.

Your Doctor or a MOH official may contact you in relation to this form.

Your pharmacy will provide on request information on potential adverse reactions that any medicine may cause.

Click here to get the Adverse Reaction Form in PDF to print and send by post or use the online form below

Note: * = Required  
First Name : 
 *
Last Name : 
 *
Address : 
 *
Suburb : 
City or Town : 
 *
State/Province : 
Country : 
Zip / Postal Code : 
Phone : 
 *
Email : 
 *
Age : 
   
Health Professional’s Name : 
Phone : 
Address : 
Suburb : 
City : 
Country : 
Condition being treated :  
Prescription Medication thought to be causing reaction :  
Date started taking themedication : 
   
Did your Health Professional inform you of possible adverse reactions to this medicine? Yes / No (please tick) : 
  
Other medications you were taking at the same time : 
Nature of adverse reaction(s) experienced : 
When did you first notice this adverse reaction? : 
Have you been back to your Health Professional about the adverse reaction? Yes / No (please circle) : 
  
Date of consultation : 
What was your Healthcare professional’s response? (e.g. stopping or changing medicine, no action etc….) : 

By pressing the Submit button a copy of this form will be sent to ;

  1. CARM (centre for Adverse Reactions Monitoring)
  2. NZ Health Trust
  3. The Ministry of Health

The NZ Health Trust will maintain your confidentiality at all times and will not release any personal details.

A copy of this form is retained by NZ Health Trust as an independent body to cross check against official Ministry Of Health data on Reported Adverse Reactions.

 
 



Click here to get the Adverse Reaction Form in PDF

 

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