Sex

Man Women

Hometown and country

Age

Report submitted by

User Relative Doctor Other

Medicine

Medicine prescribed for following
illness/condition

Dose

Start date

Stop date

Effect 1

During After During de-escalation

Effect 2

During After During de-escalation

Effect 3

During After During de-escalation

Other medicines currently being taken

Other illnesses/conditions than
that mentioned above

How has the effect influenced your regular working day

Very serious Rather serious A little Not at all

How has the effect influenced You

Your own story

Name

Address

Telephone

Telefax