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Please Help us with our Research
We Urgently Need Your Help by providing us with a formal statement setting out your experience of side effects from roaccutane / accutane.

Your name and identity need not be disclosed, however, we ask that you provide some method for us to contact you, such as email address. If you are willing to disclose your name and address, the information you provide can be included in a comprehensive scientific study that we have commissioned and which will provide a definitive description of severe side effects.(Family of patients can also complete formal statement )

Contact Details
Name

Email
Address
Phone



(home)
(other)
City

State:
ZIP

Profile of Patient
Gender

Female Male Age at date of commencement of medication
Occupation





Medication Details
Date of commencement on Accutane/Roaccutane

Duration of treatment
Prescribing Doctor
(eg. was it family doctor or a dermatologist)



Other Medications
Details on any other medications taken when you were on Accutane/Roaccutane


Side Effects
Please set out in your own words as much specific details as possible on the side effects. If you can , please include approximate date they started, whether they got worse,exactly what symptoms you felt, if you felt pains then give as much detail as pssible, if psychiatric problems, then please give every detail on what was going on in your mind.

Please try to tell it like a story starting with your first recollection of side effects and telling your experiences from week to week up to the time you finished taking the medication.The more detailed the information you provide the more valuable and helpful it is for us.
Miscellaneous
Please provide any other additional information you think appropriate, including the following;

a. Did you retain the label warning insert that was in the drug packaging. If so, can you provide us with a copy? If not, can you state if the label warning included reference to the side effect that you suffered.

b. Did you tell the prescribing doctor about the side effects? If so, can you say what was the doctor's reaction. If not, can you say why (for example many patients on Accutane/Roaccutane had no idea the medication caused serious side effects and therefore did not associate the side effects with the mdication).

c. Has your case been formally reported as side effect to Roche (the manufacturers) or to your national licensing health authority? If so, did you get formal confirmation of your case reference number and can you let us have more details so that we can check as to whether your case is formally recorded (we found that many very serious side effects reported to Roche and to dermatologists were not passed on to the national health authority). If not, was there any particular reason for not formally reporting the side effects?

d. If you disclosed side effects to the prescribing doctor during or after completion of treatment, what was the doctors reaction. did you get any help or assistance from the doctor?

e. What medications, if any, have you used to help treat the side effects, have they been effective?

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