01772 888 778
info@xyfil.com
15-19 Sedgwick Street, Preston, PR1 1TP
Open
Xyfil | Homepage | Leading UK E-liquid, CBD & Cosmetics Manufacturer
Toggle menu
Home
Products
e-liquid
cbd
cosmetics
HOW IT WORKS
SERVICES
manufacturing
White label
Compliance
INFO HUB
OUR STORY
GET IN TOUCH
VIGILANCE
Lorem ipsum dolor sit amet, consectetur adipiscing elit
Xyfil Ltd
→
Vigilance
ADVERSE EFFECTS INFORMATION COLLECTION SURVEY
Please report any adverse effects encountered whilst using our products
Are you a member of the public or a healthcare professional?
Member of the public
Healthcare professional
Profession:
--Select Profession--
Community Pharmacist
Dentist
GP
Coroner
Hospital Doctor
Hospital Healthcare Professional
Hospital Nurse
Hospital Pharmacist
Nurse
Optometrist
Other Healthcare Professional
Physician
Pharmacist
Lawyer
Chiropodist
Paramedic
Radiographer
Pharmacy Assistant/Technician
Medical Student
Midwife
Healthcare Assistant
Pre-reg Pharmacist
Reporter Details
Title:
First Name:
Surname:
Email:
Telephone:
Patient Details
Patient Initials:
Gender
Male
Female
Patient Age:
Patient Weight (in Kgs):
Kgs
Patient Height (in m):
m
Ethnicity:
---Select Ethnicity---
British
Irish
Any other white background
White and Black Caribbean
White and Black African
White and Asian
Any other mixed background
Indian
Pakistani
Bangladeshi
Any other Asian Background
Caribbean
African
Any other background
Chinese
Any other ethinic group
E-Liquid Details
Name of the Product:
Brand of E-Liquid(if different):
Manufacturer Name:
Product use start date:
Product use end date (if still using, please leave blank):
Model Number or Batch Number:
Nicotine Strength(in mg):
Flavour:
Action taken with this e-liquid as a result of the reaction:
Select action taken
Unknown
Stopped Using
Reduced Use
Not changed
Not applicable
Where did you obtain the e-liquid?
Select Source
Prescription
Bought in Pharmacy
Bought in another shop
Internet
Other
Medicine taken by mother during pregnancy
Side Effects Details
Side Effect:
Symptom start date:
Symptom end date:
Please select an outcome for each side effect:
Recovered
Recovered with some lasting effects
Getting better
Side effect continuing
Caused death
Unknown
Other (please specify)
Other Side Effect Outcome:
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):
Mild or slightly uncomfortable
Uncomfortable, a nuisance or irritation, but able to carry on with everyday activities
Had short term effect that was bad enough to affect everyday activities
Caused significant or long term incapacity
Significant enough to lead you to seek advice from a healthcare professional
Severe enough to be admitted to hospital
Caused an abnormality in an unborn child
Life threatening
Caused death
Not serious
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
Medicine Details:
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).
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
SUBMIT SURVEY
E-Liquid batch check:
CHECK
