Qiviflow

FEEDBACK - CONSUMER

Patient Initials:

Gender: Male Female Other

Age (Year or Month):

Reason(s) for taking medicine(s) (Disease/Symptoms):

Name (Optional):Address:Telephone No.:Email:

Medicine Name	Quantity of Medicines taken (e.g. 250 mg, Two times a day )	Expiry Date of Medicines	Date of Start of Medicines	Date of Stop of Medicines

If Others (Please Specify):

When did the side effect started?

Side Effect Continuing (Yes/No): Yes No None

When did the side effect stopped?What is side effect ?

Did not affect daily activitiesAffected daily activitiesAdmitted to hospitalDeathOthers

What did you do to manage the side effect?

I consent to give information on my behalf