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172 | Traditional medicine

Figure 6.12 Example of Yellow Card used by the Register of Chinese Herbal Medicine (RCHM)
to record adverse reactions.

Register of Chinese Herbal Medicine

Please fill in this form clearly in blue or black ink.

Family name .............................................

Address ............................................................................................................................................................................

........................................................................ Postcode ...........................................................................................

First name .........................................................................................

Family name ............................................. First name .........................................................................................

Date of birth .............................................

or other (please describe) ........................................................................................................................................

Prescription (please list all ingredients and brand name if applicable ....................................................

What was the herbal medicine prescribed for (e.g. Asthma) ......................................................................

Supplier of the medicine .........................................................................................................................................

Dosage of the medicine ...........................................................................................................................................

............................................................................................................................................................................................

............................................................................................................................................................................................

............................................................................................................................................................................................

............................................................................................................................................................................................

............................................................................................................................................................................................

............................................................................................................................................................................................

Type of prescription: Raw herbs/Concentrated Powder/Tincture/Pills/Cream/

(Delete as appropriate)

Male/Female ......................................... Pregnant? Yes/No

Date prescription was started ................... Date prescription was stopped (if stopped) ..................

Weight .................. Height...................... Ethnic group ....................................................................................

Telephone number ................................. First name .........................................................................................

Please note that all information is completely confidential.

2) About the patient who had the suspected adverse reaction

3) About the herbal medicine(s) that you think caused the adverse reaction

1) About you, the practitioner completing the Yellow Card report

Office 5, Ferndale Business Centre, 1 Exeter Street, Norwich

NR2 4QB.

Tel: 01603 623994

Fax: 01603 667557

Email: [email protected]

Website: http://www.rchm.co.uk

YELLOW CARD

for reporting suspected adverse events in confidence