Welcome to KILEN Consumer Data base
Reports concerning effects/side-effects of medicines



Sex

Men Female

Hometown and Country

Age

Report submitted by

Consumer Relative Doctor Other

Medicine

Medicine prescribed for following
illness/condition

Dose

Start date

Stop date

Effect 1

Under After

Effect 2

Under After

Effect 3

Under After

Other medicines currently being taken

Other illnesses/conditions than that
mentioned above

Your own story




Voluntary data concerning reporter

Name

Address

Telephone

Telefax