User of Medicine
Complete Date of birth or Age must be entered
Describe what happened
Describe what happened in your own words, any symptoms or side effects you suspect were caused by your medicine, and what happened since then. Other specific details about each medicine and relevant dates can be entered below, but please include enough information here to connect to the Reactions/Symptoms section below
Describe the reactions in your own words. Click the 'Add another reaction/symptom' button for each reaction you will describe.
Describe the reactions in your own words. Click the 'Add another reaction/symptom' button for each reaction you will describe.
Medicines
Enter the name and details for each medicine you were taking before the reaction occurred. Click on (Add another medicine) for each new medicine you need to describe. Please also describe any herbal preparations, recreational drugs or other alternative medicines you were taking.
Full name of medicine (as on the package)
Company name on package
As on package. For example: (50 mg), (10 mg/ml)
Fill in as complete as possible
Please leave blank if the medicine is still being taken
Why did you take the medicine? (For example: Diabetes, headache)
Full name of medicine (as on the package)
Company name on package
As on package. For example: (50 mg), (10 mg/ml)
Fill in as complete as possible
Please leave blank if the medicine is still being taken
Why did you take the medicine? (For example: Diabetes, headache)
Additional information
Please give a short description of your medical history. This is important since some reactions only appear with a combination of previous or ongoing disease, special diets, recreational drugs, smoking habits, alcohol intake or allergies. You can also enter other comments you feel are important.
Contact details