Drug Safety

    Patient Information


    Describe what happened

    Describe what happened in your own words, any symptoms or side affects 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.

    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.