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Submit Your Side Effect
This form allows You to submit details about
Your Side Effect experienc
e. Provided information will be posted on Patientsville.com site, please do not provide any personal information.
By submitting Your Side Effect episode you will
help others in the community recognize side effect
symptoms and improve their well being.
There are 13 questions in this survey.
A Note On Privacy
This survey is anonymous.
The record kept of your survey responses does not contain any identifying information about you unless a specific question in the survey has asked for this. If you have responded to a survey that used an identifying token to allow you to access the survey, you can rest assured that the identifying token is not kept with your responses. It is managed in a separate database, and will only be updated to indicate that you have (or haven't) completed this survey. There is no way of matching identification tokens with survey responses in this survey.
Date of Side Effect
...
Format: YYYY-MM-DD
(eg: 2003-12-25 for Christmas day)
Enter date when side effect occured.
Symptoms
What were the symptoms of the sife effect? For example: fatigue, sleeplessness, nausea, burning in throat, etc.
*
Name of a medication which caused a side effect .
Enter the name of a prescription or off-the-shelf medication patient was taming at the time when a side effect happened.
Diagnosis or Reason for Use
(Indication)
Outcomes Attributed to Side Effects
(Check all that apply)
Check any that apply
Death
Life-threatening
Hospitalization - initial or prolonged
Disability or Permanent Damage
Congenital Anomaly/Birth Defect
Required Intervention to Prevent Permanent Damage
Other Serious (Important Medical Events)
Describe Event, Problem or Product Use Error
Describe what happened.
Medication dose
Frequency of Use
Other medications used at the time of event
Other Relevant History, Including Preexisting Medical Conditions
(e.g. allergies, race, pregnancy,
smoking and alcohol use, liver/kidney problems,etc.)
*
Patient's Age at the time of event.
Only numbers may be entered in this field
Enter age of the patient at the time when the side effect happened.
*
Select patient's gender.
Female
Male
Patient's weight at the timeof event.
Only numbers may be entered in this field
Enter patient's weight at the time when side effects occured.
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