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Complete a RxISK Report
1
Contact details
2
The person
3
The drug
4
Other meds
5
Side effect
6
RxISK score
7
Impact
8
Drug review
9
Preview
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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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*
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
Contact information is necessary to email you a copy of the RxISK report and RxISK score.
Email
*
Enter Email
Confirm Email
May we contact you?
*
Yes
No
The RxISK research team may want to follow up with you to clarify or get additional information for research.
Would you like to receive our monthly newsletter?
*
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 effect
Supply as much information as you can. Include any medical history or other information you believe may help in the assessment of the side effect.
Who experienced the suspected side effect?
Me
My child
Someone in my care
My patient
My client (I am a lawyer)
Gender
*
Male
Female
Other
Country
*
Please select
Canada
United Kingdom
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
France
French Polynesia
Gabon
Gambia
Georgia
Germany
Ghana
Greece
Greenland
Grenada
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Norway
Northern Mariana Islands
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia and Montenegro
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Sudan, South
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Yemen
Zambia
Zimbabwe
Age
*
Years | Months
*
Years
Months
Days
Known medical conditions
Please list one condition per line. Click on the plus sign (+) at the end to add another entry.
Medication allergies (please specify)
Allergic to:
Reaction experienced:
Please 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 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
Started
Select
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
Select
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Select
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Select
mg
mcg
mcg|puff
unit
other
Select
1 x per day
2 x per day
3 x per day
4 x per day
as needed
other
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
Select
Increased dose
Decreased dose
Select
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
Select
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Select
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Select
mg
mcg
mcg|puff
unit
other
Select
1 x per day
2 x per day
3 x per day
4 x per day
as needed
other
Suspect drug stop date
Please provide the approximate date of stopping the suspect drug (if applicable).
Change
Year
Month
Day
Stopped
Select
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
Select
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Select
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
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 5 — About the primary side effect
Provide as much information as possible to describe the primary side effect, including dates, symptoms experienced and their severity.
Describe the primary side effect you suspect was caused by the drug and its impact on the person in as much detail as possible. [share#]
*
#No contact details will be published.
Primary side effect timeline
Change
Year
Month
Day
Severity
Started around
Suddenly decreased around
Progressively increased until
Progressivley decreased until stopping
Suddenly increased around
Suddenly stopped around
Progressively decreased until
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2001
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Select
Very mild
Mild
Medium
High
Extreme
Please provide the approximate start date and the dates of any changes to the primary side effect. Click on the plus sign (+) at the end to add another entry.
At present the primary side effect
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 death
YYYY dash MM dash DD
If 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.
Please 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
Section 6 — RxISK causality score
These questions help assess the likelihood that the primary side effect is linked to the suspect drug.
Do you link the side effect to:
*
Starting or taking the drug
Reducing dose / Tapering off the drug
Stopping the drug
Not sure
Did the side effect start before or after REDUCING the dose of the drug?
*
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?
*
Different from the original condition
Re-emergence of original condition
Don't know
Did the side effect start after STOPPING the drug?
*
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?
*
Cleared on restarting
Didn't clear
Didn't restart
Did the side effect improve if the person INCREASED the dose of the drug?
*
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?
*
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?
*
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.")
*
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?
*
Yes, on the same type of drug
Yes, on another type of drug
No
Could anything else be causing this side effect?
*
Yes
No
Don't know
What else do you suspect might be causing this side effect?
Are there previous reports of side effects on STOPPING the drug in the RxISK database or in a drug regulator database (e.g., FDA, Health Canada, Yellow Card) or elsewhere?
*
Yes
No
Don't know
Did the side effect begin after the person STARTED the drug?
*
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?
*
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?
*
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?
*
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?
*
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?
*
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.")
*
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.")
*
Yes
No
Don't know
Could anything else be causing this side effect?
*
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?
*
Yes
No
Don't know
Could the person have taken too high a dose?
*
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?
*
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?
*
Yes
No
No one has reviewed the side effect
Is this side effect a rare condition in people not on a drug?
*
Very rare
Rare
Don't know
Are there previous reports of side effects on STARTING the drug in the RxISK database or in a drug regulator database (e.g., FDA, Health Canada, Yellow Card) or elsewhere?
*
Yes
No
Don't know
Section 7 — Impact
What 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 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.
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