ADVERSE MEDICINES EVENTS LINE

Reporting a Side Effect from your Medication

Complete this form to report a Side Effect from your medication. If you wish to report a medicine incident or error, go to the Reporting a Medicine Incident or Error form.

Who had the side effect?

Gender:

Male
Female

Postcode:

If not in Australia, what country?

Age:

 years

 months ( if baby )

Report submitted by?

Consumer (self)
Relative
Doctor
Other

If other, please specify:

About the medicine(s) you suspect caused the side effect:
 (Details can be found on the label or packaging)

Medicine 1

Name of Medicine
Dosage
How did you take the medicine
Reason for use
When did you start taking the medication? -- date or approx time
When did you stop taking the medication? -- date or approx time
If stopped, by whom? (eg self, doctor, pharmacist)

Medicine 2

Name of Medicine
Dosage
How did you take the medicine
Reason for use
When did you start taking the medication? -- date or approx time
When did you stop taking the medication? -- date or approx time
If stopped, by whom? (eg self, doctor, pharmacist)

Medicine 3

Name of Medicine
Dosage
How did you take the medicine
Reason for use
When did you start taking the medication? -- date or approx time
When did you stop taking the medication? -- date or approx time
If stopped, by whom? (eg self, doctor, pharmacist)

List other medicines (or herbal remedies) by brand name taken within 3 months of the reaction?
Details can be found on the label or packaging.

Date of event or symptoms:

-- dd/mm/yy or approximate date

Description of the event or symptoms

Outcomes attributed to the medicine incident
(check all that apply)

    Nil    Birth Defect
    Death    GP Consultation
    Danger to life    Worsened quality of life
    Hospital Admission    Absence from Productive Activity (eg time off work)
    Hospital Stay Prolonged    Ongoing Treatment Required (eg physio, rehab)
    Hospital Visit, Not Admitted  

Did this medicine incident result in any medicine changes?
(check all that apply)

Dose changed    Drug continued  Drug ceased     Drug Replaced

Your own story

Optional Information:

Contact information:

Name
Telephone(incl STD code)
E-mail
Funded by The National Prescribing Service,  operated by Mater Misericordiae Health Services Brisbane Limited. NPS is a non-profit, independent organisation for Quality Use of Medicines funded by the Australian Government Department of Health and Ageing