Reporting side effects

If you notice side effects that may be caused by the use of Profarma sh.a. medicines, do not hesitate to inform us.

For this purpose you may contact us by:

Email: drug.safety@profarma.al

Address: Profarma sh.a., Rruga “Myslym Keta” 1022, Tirana, Albania

The Reporting Formulary

Please note that you must fill in a minimum of data which are marked with (*) without which the formulary can not be sent. All the other fields serve to check out better your reporting. Your data will be stored for documentary purposes in our archive and will be kept confidential.

In case of medical emergencies please contact immediately your doctor, pharmacist and / or the emergency department.

Please complete the following formulary and then click. “Submit"

1) To whom does this report apply?:

This report is about(*)

Choose an option

2) Informations about the patient who experienced the side effect

Name, Last Name or Initials (*)
Ju lutem shkruni emrin e plote.

Birthday(*)
/ / Invalid Input

Age at the time of appearance of the side effect
Invalid Input

Sex(*)

Please choose an option!

Height (cm)
Ju lutem vendosni gjatesine.

Weight (kg)
Ju lutem vendosni peshën

Pregnancy, week

3) Informations about the drug that is suspected to have caused the side effect

Drug name and dose (e.g. Fasdol® 400 mg)(*)
Please write the drug name and dosage

Batch number (located on the packaging, e.g. 1701)
Please write the batch number

Reason for taking / using the drug (e.g. pain, high blood pressure)
Please write the reasons.

Dosage (e.g. 400 mg twice daily)(*)
Please write the dosage

Administration route (e.g. by mouth, cutaneously) (*)
Please fill the field!

When did the patient start taking/using the medicine? (*)
/ / Invalid Input

When did the patient stop taking / using the medicine?(*)
/ / Invalid Input

Do you continue to take/use this medicine?
Invalid Input

4) Informations about the experienced side effect

Date of the side effect occurrence
/ / Invalid Input

Description of the signs / symptoms (e.g. itching, redness etc.)(*)
Të dhëna të pavlefshme !

Evaluate the severity of the side effect(*)
Të dhëna të pavlefshme !

By evaluating the effect as serious you mean more (more than one alternative may be chosen)

Invalid Input

Other(*)
Invalid Input

What is noticed over time regarding the side effect?

Invalid Input

Death Date
/ / Invalid Input

Other
Invalid Input

Did the signs / symptoms disappear after the dose reduction or interruption of the drug?

Te dhena te pavlefshme

Did the signs / symptoms occur again after the patient started taking / using the same drug again?

Invalid Input

5) Additional information

List any other drug that you are taking / using or have taken / used in the last 3 months
(including over the counter medicines, herbal medicines or food supplements), the
purpose of their use and the duration of use.

Invalid Input

Give as much details as possible about the previous drugs effects, known allergies or
intolerance, other existing diseases, smoking, alcohol use, known results of the
analysis or any other information you consider important.

Plotesoni fushen

6) Contact information

Do you permit us to contact the doctor who has prescribed the drug to provide more information?

Invalid Input

Doctor's Name and Surname
Invalid Input

Address / Health Care Unit where he/she works
Invalid Input

Doctor's Email
Invalid Input

Doctor's Telephone
Të dhëna të pavlefshme !

7) Informations about the reporter

Name, Surname(*)
Të dhëna të pavlefshme !

Telephone(*)
Jo i vlefshem

Email
Ju lutem shkruani adresen e emailit.

Profession (in case the reporter is a health professional)
Të dhëna të pavlefshme !

Address(*)
Ju lutem shkruani adresen.

Town(*)
Ju lutem shkruani qytetin.

Postal Code
Jo i vlefshem

Country(*)
Jo i vlefshem

The patient and the reporter are the same person?(*)
Invalid Input

Type the text(*)
Type the text   RefreshInvalid input!


Thank you for contributing in the safety and efficacy of use of Profarma sh.a. medicines!

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