Complete a RxISK Report

1Contact details

2The person

3The drug

4Other meds

5Side effect

6RxISK score

7Impact

8Drug review

9Preview

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I acknowledge that I have read and fully understand the Terms and Privacy Policy (see links below) of Data Based Medicine Americas 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.
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Share*
- 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 details
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Email*
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May we contact you?*
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- No
The RxISK research team may want to follow up with you to clarify or get additional information for research.
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Section 3 — About the drug suspected to have caused the side effect
A person who has experienced a side effect should consult a health care practitioner about this and ideally bring this report with them.
Suspect drug*
Which drug do you suspect is causing (or has caused) the side effect? Please enter only one drug.
Reason for taking the suspect drug
Suspect drug start date*
Please provide the approximate start date of the suspect drug.
Change Year Month Day Dose Unit Frequency
Suspect drug dose/frequency changes
Please provide the approximate date of any dose/frequency changes (if applicable). Click on the plus sign (+) at the end to add another entry.
Change Year Month Day Dose Unit Frequency
Suspect drug stop date
Please provide the approximate date of stopping the suspect drug (if applicable).
Change Year Month Day

Section 4 — About other drugs or medications used at the same time
The 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 name Reason for taking How long taking? Any changes around the date of the primary side effect?

Click 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 name Reason for taking

Click on the plus sign (+) at the end to add another entry.
Other relevant information (e.g., smoking, pregnancy, alcohol use, etc.)

Section 8 — Drug review
How you feel about a drug depends on how its benefits balance against unwanted side effects. This section lets others know whether, on balance, the person taking the drug feels the drug was "worth it." Please note that we may publish some of the information from this section. Sharing stories and not just numbers of reports is hugely valuable in allowing others to learn from your experience and understand their own. Please remove any information you don’t wish to share with other people (especially if it might allow people to identify you in some way).
Considering 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#]
#No contact details will be published.
What advice would the person give to someone who was considering taking the drug? [share#]
#No contact details will be published.
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#]
#No contact details will be published.
Hidden
Report Share Code

Section 1 — Contact details

Prescription drug name	Reason for taking	How long taking?	Any changes around the date of the primary side effect?

Allergic to:	Reaction experienced:

Change	Year	Month	Day	Dose	Unit	Frequency

Change	Year	Month	Day	Severity