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Traditional Chinese medicine | 173

Figure 6.12 Continued

Did you consider the reaction to be serious? Yes/No

How bad was the suspected adverse reaction? – please tick:

• Mild or slightly uncomfortable


• Uncomfortable, a nuisance or irritation, but able to carry on with everyday activities


• Bad enough to affect day to day activities, i.e. persistent or significant disability or incapacity


• Bad enough to be admitted to hospital


• Life-threatening


• Caused death


• Caused congenital abnormality


• Getting better


• Still has reaction


• Recovered but with some lasting effects (please describe these below) ........................................


• Recovered completely

Please describe the suspected adverse reaction in your own words including any treatment

received for the reaction ..........................................................................................................................................

Date adverse reaction started ...............................................................................................................................

Has the adverse reaction stopped? Yes/No If yes, what date did it stop? .........................................

Was the patient rechallenged? Yes/No If yes, at what dose ...................................................................

Did the adverse reaction re-occur? Yes/No

Other medical conditions including known sensitivities ..........................................................................

How is the patient now? – please tick

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RCHM YELLOW CARD continued

4) About the suspected adverse reaction

5) More information about the person who had the adverse reaction