174 | Traditional medicine
Figure 6.12 Continued
Please list any other medicines (including your own previous prescriptions, prescribed
medicines and other herbal remedies) used three months prior to the suspected adverse
reaction including the name of the medicine, the dosage, what it was used for, when
started, and when stopped.
Name of medicineYes/No/Don’t know (please delete as appropriate)Yes/No/Don’t know (please delete as appropriate)Are you happy for the MHRA to contact you in the future to discuss the suspected adverse
reaction or ask for more information? Yes/NoThe RCHM provides a service whereby the Yellow Card information that you have submitted,
along with a full case history, can be analysed by an expert practitioner. This process is completely
anonymous and confidential. If you wish for your Yellow Card report to be sent for analysis
then please enclose a copy of your full case history notes and tick this boxIf yes, did the health professional complete a Yellow Card report?Please give any other information that you think might be relevant including test results, oriental
medical diagnosis e.g. patient yang xu treating for wind heat attack, dietary information, your
conclusions and suggestions. For congenital abnormalities please state all other drugs taken
during pregnancy and the last menstrual period. Please continue on a separate sheet if necessary.Was a doctor, pharmacist or other health professional told about the suspected adverse reaction?Type of medicine Source Used for? Dosageand type of medicine
e.g. pill, powder, cream
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including brand e.g. external cream, started stopped
name if known raw herbs, powderRCHM YELLOW CARD continued
6) Other medicines7) Additional information and comments8) Would you like your Yellow Card submission to be analysed by an expert?9) Finally, please sign and date this Yellow Card submission, thank you.Signed (practitioner signature) ........................................................................... Date ......................
Please return this form to: Yellow Card Report, Register of Chinese Herbal Medicine, Office 5,
Ferndale Business Centre, 1 Exeter Street, Norwich, NR2 4OB.