Background Information
This information is being entered by:
Do you think one or several medications are making the patient worse?
Which of the following has happened to the patient in the last six months (check all that apply)?
Patient Sex:
Patient Date of Birth:
/ /
Patient Zip Code:
Medications Patient is Taking (click "Brand" at the top of the list to choose by brand name)
Medication 1:
Symptoms Patient is Experiencing
No symptoms have been entered.
Create Report - Are Your Medications Making You Sick?
When you are sure the above information is correct, please press the Create Report button below.