Procedure Side Effects Intake Form
Please provide detailed information about any side effects you have experienced following your procedure. Your responses help us ensure your safety and improve care.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Procedure Name or Type
*
Date of Procedure
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Please indicate any side effects you have experienced after your procedure.
*
Rows
Experienced (Yes/No)
Severity
Onset (Days after procedure)
Duration (in days)
Nausea
1
Mild
Moderate
Severe
Vomiting
2
Mild
Moderate
Severe
Pain at procedure site
3
Mild
Moderate
Severe
Swelling
4
Mild
Moderate
Severe
Fever
5
Mild
Moderate
Severe
Dizziness
6
Mild
Moderate
Severe
Rash or skin reaction
7
Mild
Moderate
Severe
Shortness of breath
8
Mild
Moderate
Severe
Other
9
Mild
Moderate
Severe
If you selected 'Other' as a side effect, please describe it below.
Have you taken any actions or medications to address these side effects?
*
Yes
No
If yes, please specify the actions or medications taken.
Do you have any pre-existing medical conditions?
*
Yes
No
If yes, please list your pre-existing medical conditions.
Are you currently taking any regular medications?
*
Yes
No
If yes, please list your current medications.
Additional comments or information you would like to share
Submit Side Effects Report
Should be Empty: