CASE:
Date
form filled:
(A)
GENERAL DETAILS
1.
Name of respondent:
Patient/parent/spouse/other
2.
Name of patient, if different from 1:
3.
Age of patient:
4.
Address:
5.
Telephone:
Current
health status (own words):
7.
Suspected drug:
Septrin/Bactrim/co-trimoxazole
8.
Date of prescription:
9.
Dosage and duration recommended:
10.
For what condition:
11.
Was an other medicine prescribed
simultaneously? Yes/No/Forgotten.
If
"Yes", what?
Any
others?
12.
Were you taking any medicine
immediately prior to the drug?
Yes/No/Forgotten
If
"Yes", what?
Any
others?
13.
By whom was the suspected drug
prescribed: General Practitioner/GP
locum/hospital doctor
14.
Name of the prescribing doctor:
15.
Names of other doctors involved in
case, with reason for involvement:
16.
Had you been prescribed
Septrin/Bactrim/co-trimoxazole
before? Yes/No/Forgotten
If
"Yes", when, for what
and with what result?
(B) INITIAL CONSULTATION AND
PRESCRIPTION
1.
Were any diagnostic tests or other
procedures carried out before, or at
the time of, prescription?
Yes/No/Forgotten
If
"Yes", specify:
2.
Did either you or the doctor initiate
discussion of possible side-effects
of the drug at the time of
prescription? Yes/No/Forgotten
If
"Yes", was it:
(a)
You, or
(b)
The doctor?
If
(a) or (b), what was said?
3.
Did the doctor consult and reference
book? Yes/No/Forgotten
4.
Did the doctor ask about any known
allergies/sensitivities?
Yes/No/Forgotten
If
"Yes", what was said?
(C)
SUSPECTED REACTION
1.
What was the first sign that there
may be something amiss with the
treatment?
2.
How long after commencing the course
did the first sign of a possible
reaction occur?
3.
Was there a rash? Yes/No (this may,
or may not, repeat 1)
4.
How many tablets, approximately had
been taken?
5.
Were there any further immediate
symptoms before you consulted a
doctor again? Yes/No
If
"Yes", specify:
6.
Did you discontinue the drug before
consulting doctor? Yes/No/Forgotten
(D)
MEDICAL RESPONSE TO SUSPECTED
REACTION
1.
Where did you seek medical help?
(a)
From general practitioner
(b)
From hospital
If
(a) Did you see the same
doctor? Yes/No
If
"No", who did you
see?
If
(b) Which hospital?
If
(b) Were you admitted as an
inpatient? Yes/No
2.
Were you advised to continue with the
drug?
3.
What was said to explain decision (at
2) above?
4.
Was any diagnosis given to you at
this stage?
5.
Did you receive any further
medicines? Yes/No/Forgotten
If
"Yes", what?
6.
Did either you or the doctor initiate
discussion of possible side-effects
of the drug at this stage, after the
suspected reaction? Yes/No/Forgotten
If
"Yes", was it:
(a)
You, or
(b)
The doctor?
If
(a) or (b), what was said?
7.
After this consultation, did your
health (a) improve, (b), stabilise,
(c) deteriorate further?
Please
explain:
(E)
SUBSEQUENT INCIDENTS
1.
Have you experienced subsequent acute
incidents or medical crises? Yes/No
If
"Yes", explain:
2.
Have you undergone surgery? Yes/No
If
"Yes", what procedures
and for what suspected
complaints?
3.
How many hospital doctors have
examined you?
(F)
CONTINUING HEALTH PROBLEMS
1.
Please list any conditions from which
you currently suffer (do not record
allergies here):
i.
ii.
iii.
iv.
v.
vi.
vii.
viii.
ix.
x.
2.
Which of these do you believe are
unlikely to be consequences of the
drug, but are coincidental?
3.
Are you registered disabled? Yes/No
(G)
RESPONSE TO CHRONIC CONDITIONS
1.
Do you receive any continuing
professional support for your
conditions? Yes/No
If
"Yes":
(a)
Family doctor
(b)
Hospital specialist
(c)
Other medical specialist
(d)
Alternative practitioner
(e)
Other
2.
What explanations have you been given
for your chronic conditions and by
whom?
3.
Has it been suggested that your
symptoms are psychological or not
real? Yes/No
If
"Yes", by whom?
4.
Are you currently taking any
prescription medicine? Yes/No
If
"Yes", which?
5.
Do you observe a special diet? Yes/No
If
"Yes", give a general
description.
6.
Are there any foods you specifically
avoid? Yes/No
If
"Yes", please itemise
i.
ii.
iii.
iv.
v.
vi.
vii.
viii.
ix.
x.
7.
To your knowledge, do you suffer from
allergies other than to food? Yes/No
If
"Yes", what are they?
8.
Do you smoke? Yes/No
9.
Do you take vitamins or dietary
supplements? Yes/No
If
"Yes", which?
10.
Are there any other factors which you
feel aggravate your complaints, or
make your overall health worse?
(H)
CONCLUSION
1.
Are you in any doubt as to the cause
of your condition? Yes/No
If
"Yes", what is it?
2.
At what time did you form this
judgement?
3.
How would you summarise the effect of
all this on your life?
4.
Has the original prescribing doctor
appeared to accept that your
condition is the result of taking
this drug? Yes/No
Please
summarise your opinion of his/her
apparent attitude.
5.
Has any other doctor accepted that
the drug may be responsible? Yes/No
6.
Is there anything you feel we have
missed?
7.
Have you consulted a lawyer? Yes/No
If
"Yes", what has happened?
8.
Would you be willing to take phone
calls from people who may appear to
suffer from similar problems as
yourself?