Are you a member of the public or a healthcare professional? *

Member of the public
Healthcare professional

Profession *

Reporter Details

Title *

First Name *

Last Name *

Email *

Telephone *

Patient Details

Patient Initials *

Gender

Male
Female

Patient Age *

Patient Weight (in Kgs) *

Patient Height (in m) *

Ethnicity *

E-Liquid Details

Name of the Product *

Batch Number *

Product use start date *//

Product use end date (if still using, please leave blank)//

Nicotine Strength (in mg) *

Product Flavour *

Action taken with this e-liquid as a result of the reaction *

Where did you obtain the e-liquid? *

Side Effects Details

Side Effect *

Side Effect Start Date *//

Side Effect End Date *//

Please select an outcome for each side effect

If the appropriate term for the side effect is not listed above, please describe the side effects in your own words in the box provided (including the sequence of events, any treatment received, or any other relevant information)

Please describe how the side effects affected you by selecting from the options below (select all that apply) Please select at least one option

Additional Details

Please use the below sections to tell us about any medicines you are taking, and any underlying medical conditions or allergies. Are any medicines being taken, or have been taken in the last 3 months (including prescription, over the counter or herbal medicines)? *

Yes
No
Unknown

Other information you think might be important, including any other medical condition, any allergies that the person may have, results of any tests performed etc. If you are reporting an adverse reaction to an e-cigarette, please provide as much information as you can on the e-cigarette usage (e.g. how often the e-cigarette was used, how many inhalations in a typical period of use and details of current/history of smoking habits). Please also include details of use of other tobacco products (e.g. cigarettes), length of time have smoked, whether this is ongoing or the date stopped).

Type your answer for the above question here *

Was a doctor, pharmacist or other healthcare professional told about the suspected side effect? *

Yes
No

Did your doctor, pharmacist or other healthcare professional complete a Yellow Card on your behalf? *

Yes
No

Are you happy for the MHRA to contact you in the future to discuss the suspected side effect or ask for additional information that might help us better understand the case? *

Yes
No

Would you like a copy of this report to be sent to your GP surgery/practice or any other healthcare professional? *

Yes
No

If we need further information to help us understand the case (e.g. medical information, test results, etc.) do we have your permission to contact your doctor directly for it? *

Yes
No

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Reporter Details

Patient Details

E-Liquid Details

Side Effects Details

Additional Details

Are you of legal vaping age?