Complete a RxISK Report Step 1 of 9 11% Terms of Service(Required) I agree to the Terms of ServiceI acknowledge that I have read and fully understand the Terms and Privacy Policy (see links below) of Data Based Medicine Global Ltd. and its family of websites. Further, I acknowledge that I have read and fully understand the risks, limitations, and conditions of use of email to send me a copy of the RxISK Report. Other than an email address, I will not provide any personally identifiable information for myself or the person who may have experienced a side effect.Links to Terms and Privacy Policy (opens in new window)Share(Required) Yes, please share my comments to help others No, I don’t want my comments to be shared We would like your permission to publish some of your comments from the report. These questions are marked [share]. Sharing stories and not just numbers of reports is hugely valuable in allowing others to learn from your experience and understand their own. PLEASE NOTE THAT NO CONTACT DETAILS WILL BE PUBLISHED.Section 1: Contact detailsContact information is necessary to email you a copy of the RxISK report and RxISK score.Email(Required) Enter Email Confirm Email May we contact you?(Required) Yes No The research team may want to follow up with you to clarify or get additional information.This field is hidden when viewing the formWould you like to receive our newsletter?(Required) Yes No Our newsletter contains a recap of posts on RxISK and davidhealy.org, plus any other important news. Section 2: About the person who experienced the side effectWho experienced the suspected side effect? Me My child Someone in my care My patient My client (I am a lawyer) Other Gender(Required) Male Female Other Country(Required) AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Age(Required)Known medical conditions Add RemovePlease list one condition per line. Click on the plus sign (+) at the end to add another entry.Medication allergies (please specify)Allergic toReaction experienced Add RemovePlease list one medication allergy per line. Click on the plus sign (+) at the end to add another entry. Section 3: About the drug suspected to have caused the side effectA person who has experienced a side effect should consult a health care practitioner about this and ideally bring this report with them.Suspect drug(Required)Which drug do you suspect is causing (or has caused) the side effect? Please enter only ONE drug.Reason for taking the suspect drugSuspect drug start date(Required)YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031Please provide the approximate start date of the suspect drug.Suspect drug stop dateYearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031Please provide the approximate date of stopping the suspect drug (if applicable). Section 4: About other drugs or medications used at the same timeThe side effect may have been caused by other prescription drugs or non-prescription medications, or by the combination of products.List any other PRESCRIPTION DRUGS the person was taking at the same time as the suspect drug.Prescription drug nameReason for takingHow long taking?Any changes around the date of the primary side effect? Add RemoveClick on the plus sign (+) at the end to add another entry.List any NON-PRESCRIPTION MEDICATIONS (e.g., supplements, herbals, vitamins, etc.) the person was taking at the same time as the suspect drug.Non-prescription medication nameReason for taking Add RemoveClick on the plus sign (+) at the end to add another entry.Other relevant information (e.g., smoking, pregnancy, alcohol use, etc.) Section 5: About the primary side effectDescribe the primary side effect you suspect was caused by the drug and its impact on the person in as much detail as possible. [share](Required)At present the primary side effect(Required) is continuing has stopped What impact did the primary side effect have? (select all boxes that apply) Mild Unpleasant, but did not affect everyday activities Bad enough to affect everyday activities Bad enough to see a doctor Bad enough to be admitted to hospital Caused serious illness Caused death Other Date of deathYearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031If you selected "Other" above, please provide more detail on the impact of the primary side effect.Provide available details of laboratory tests (e.g., blood and urine tests, bone density scans, etc.) performed in connection with the primary side effect.Describe any treatment taken for the primary side effect (e.g., pain relievers).List any other side effects you suspect were caused by the drug. Add RemovePlease list one side effect per line. Click on the plus sign (+) at the end to add another entry.How is the person feeling now? Better (no more symptoms) Getting better Continuing bad (still has symptoms) Getting worse Died Other Section 6: RxISK causality questionsThese questions help assess the likelihood that the primary side effect is linked to the suspect drug.Do you link the side effect to:(Required) Starting or taking the drug Reducing dose / Tapering off the drug Stopping the drug Not sure Did the side effect begin after the person STARTED the drug?(Required) Side effect began after starting the drug Side effect began before starting the drug Don’t know Did the side effect begin or get worse after a dose INCREASE?(Required) Began/got worse after dose increase No change with dose increase Didn’t increase the dose Did the side effect improve when the person LOWERED the dose?(Required) Improved on lowering the dose Didn’t improve on lowering the dose Didn’t lower the dose Did the side effect improve when the person STOPPED the drug?(Required) Cleared on stopping the drug Didn’t clear on stopping the drug Didn’t stop the drug Did the side effect clear up with ANOTHER treatment?(Required) Cleared with another treatment Didn’t clear with another treatment Didn’t try another treatment Did the side effect reappear or get worse when the person RESTARTED the drug?(Required) Reappeared or got worse on restarting Didn’t reappear or get worse on restarting Didn’t restart the drug Has the person ever experienced this side effect before on any other drug? (If the experience was different in any way answer "No.")(Required) Yes, on same type of drug Yes, on another drug No Has the person ever experienced this side effect when not on a drug? (If the experience was different in any way answer "No.")(Required) Yes No Don’t know Could anything else be causing this side effect?(Required) Yes No Don’t know What else do you suspect might be causing this side effect?Is the person a poor metabolizer of drugs, does the person need lower doses, or does the person have a history of sensitivity to drugs?(Required) Yes No Don’t know Could the person have taken too high a dose?(Required) Yes No Don’t know Have any of the person's blood relatives ever experienced this side effect when on the same or a similar drug?(Required) Yes No Don’t know If a doctor or pharmacist has reviewed this side effect, does he/she see a link between the side effect and the drug?(Required) Yes No No one has reviewed the side effect Is this side effect a rare condition in people not on a drug?(Required) Very rare Rare Don’t know Are there previous reports of this side effect on STARTING the drug in RxISK posts, medical articles, internet forums, or in a drug regulator's database (e.g., FDA, Health Canada, EMA, TGA, Yellow Card)?(Required) Yes No Don’t know Did the side effect start before or after REDUCING the dose of the drug?(Required) Side effect started after reducing the dose Side effect was there before reducing the dose Didn’t reduce the dose Was the side effect different from the original condition for which the drug was prescribed?(Required) Different from the original condition Re-emergence of original condition Don’t know Did the side effect start after STOPPING the drug?(Required) Side effect started or got worse after stopping Side effect stayed the same after stopping Didn’t stop the drug Did the side effect improve or clear up if the person RESTARTED the drug?(Required) Cleared on restarting Didn’t clear Didn’t restart Did the side effect improve if the person INCREASED the dose of the drug?(Required) Improved on increasing the dose Didn’t improve on increasing the dose Didn’t increase the dose How soon after RESTARTING the drug or INCREASING the dose did the problem improve?(Required) Cleared within a week Cleared within a month Cleared after a month Didn’t restart the drug or increase the dose Did the problem improve on a related drug?(Required) Cleared with related drug Didn’t clear with related drug Didn’t try a related drug Has the person ever experienced the SAME side effect on STOPPING another drug? (If the experience was different in any way answer "No.")(Required) Yes, on the same type of drug Yes, on another type of drug No Don’t know Has the person ever experienced any OTHER side effects on STOPPING another drug?(Required) Yes, on the same type of drug Yes, on another type of drug No Could anything else be causing this side effect?(Required) Yes No Don’t know What else do you suspect might be causing this side effect?Are there previous reports of this side effect on STOPPING the drug in RxISK posts, medical articles, internet forums, or in a drug regulator's database (e.g., FDA, Health Canada, EMA, TGA, Yellow Card)?(Required) Yes No Don’t know Section 7: ImpactWhat is the overall impact of the primary side effect on the person? This information can be most important in understanding what is happening.Physical activities:Did the side effect limit the person's physical activities or ability to do things? Yes No Don’t know How much of an impact did the side effect have on the person's physical activities or ability to do things? Very little Some Quite a lot Extreme (life altering) If you'd like, tell us the story behind the rating you've chosen.Mental abilities:Did the person experience a change in any of his or her mental abilities, psychological state, or behaviour as a result of the side effect? Yes No Don’t know How much of an impact did the side effect have on the person's mental abilities, psychological state, or behavior? Very little Some Quite a lot Extreme (life altering) If you'd like, tell us the story.Work impact:Was the person's work affected (paid or unpaid) as a result of the side effect? Yes No Don’t know Is the person paid or unpaid in their primary work role? Paid Unpaid How many days off work?How many days was the person's work performance impaired?Social activities:Did the person experience any change in his or her usual social activities, friendships, or relationships as a result of the side effect? Yes No Don’t know Describe the change in the person's usual social activities, friendships, or relationships.Other impacts:Please list any other changes that haven't been covered.Examples: greater or lesser desire to drink alcohol or take drugs, change in the effects of the person’s usual drugs or alcohol, change of odour affecting the person’s relationship, change in interests, change in political affiliation, good or bad effects on personality or sense of physical or mental well-being, good or bad effects on other conditions, another unrelated condition getting better. Section 8: Drug reviewConsidering both the treatment of the person's condition and the side effect(s) they experienced, how would they rate their experience on the drug? Very satisfied Satisfied Neutral Unsatisfied Very unsatisfied Did the person continue taking the drug? Yes No Please explain why. [share]What advice would the person give to someone who was considering taking the drug? [share]Did the person or their doctor or pharmacist find ways to reduce the side effect(s) of the drug other than stopping the drug or reducing the dose? Yes No Please describe them. [share]Report Share Code Section 9: Preview your submission{all_fields:noadmin}CAPTCHA Δ
