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Which of the following were you?
Patient age:
Patient gender:
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Brand Name of the Drug:

(Enter N/A if it is a generic medication)
Generic Name:

(Enter N/A if it is a brand name drug)
What condition/problem you took this drug for?
What was the dose?
How often did you take/receive it?
How long did you take/receive it?
How effective was this drug:
How much side effects/adverse reactions did you have:
Rate your overall experience with this drug:

(10 - very positive; 1 - very negative)
What other conditions did the patient have?
What other drugs was the patient taking?
What were the treatment benefits?
What were the treatment side effects?
Please describe the treatment details.


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