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15-19 SEDGWICK STREET

Preston, PR1 1TP

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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:

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):

Ethnicity:

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:

Where did you obtain the e-liquid?

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

E-Liquid batch check:

Established in 2014, Xyfil Ltd are a UK leading e-liquid manufacturer. We provide end-to-end manufacturing services so whether you are a new brand or a well-established e-liquid business, we can help you to grow your brand and customer base.

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Contact Details

Address: Xyfil LTD, 15-19 Sedgwick Street, Preston, Lancashire, PR1 1TP.

Call Us On: +(44) 1772 888 778

Mail Us At: info@xyfil.com

Opening Times: Mon - Fri: 9am to 6pm