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?