Home
Contact
Staff
New Zealand
Pharmacovigilance Centre
Home
CARM
CARM Database
Caveat
Data Privacy
Medical Warning System
Analysis
Database Extracts
Feedback
Reporting
REPORTING FORMS
How to Report
Who can Report
What to Report
What to Include
M2 Monitoring
About Reporting
Patients & Public
REPORTING FORMS
How to Report
What to Report
What to Include
Company Report
Patient
Surname
First names
Female
Male
DOB
NHI
Ethnicity
Town/City
Psychoactive & Recreational Substances
4:20 (SGT-42) [50mg per gm]2.5gm
Add
Amsterdam Havana Special (AB-FUBINACA) [50mg per gm]2.5gm
Add
Amsterdam Long Island Tea (CL-2201) [50mg per gm]2.5gm
Add
Apocalypse (AB-FUBINACA) [2.5gm - 0.107gm 5.00gm - 0.214gm] 2.5gm 5gm
Add
B-52 Berry Bomb (PB-22) [50mg per gm]2.5gm
Add
Blueberry Crush (AB-FUBINACA) [50mg per gm]2.5gm
Add
Choco Haze (AB-FUBINACA) [50mg per gm]2.5gm
Add
Diablo (SGT-24) [50mg per gm]2.5gm
Add
DC-3 Purple (5F-PB-22) [50mg per gm]2.5gm
Add
Dr Feelgood (Amino acids, caffeine, kava, citrus aurantium extract) [50mg per gm]2.5gm
Add
Giggle (SGT-24) [50mg per gm]2.5gm
Add
Haze (PB-22) [50mg per gm]2.5gm
Add
illusion Colossus (CL-2201) [50mg per gm]2.5gm
Add
illusion Connoisseur (5F-PB-22) [50mg per gm]2.5gm
Add
illusion Massif (5F-PB-22) [50mg per gm]2.5gm
Add
illusion Peak (AB-FUBINACA) [50mg per gm]2.5gm
Add
Jungle Juice (CL-2201) [50mg per gm]2.5gm
Add
Lemon Grass (AB-FUBINACA) [50mg per gm]2.5gm
Add
Master Kush (AB-FUBINACA) [50mg per gm]2.5gm
Add
Mind Trip (PB-22) [50mg per gm]2.5gm
Add
Nirvana (Caffeine, citrus Aurantium extract, amino acids, kava extract, Vitamin B6) [50mg per gm]2.5gm
Add
Northern Lights Black Label Skunk (PB-22) [50mg per gm]2.5gm
Add
Outbreak (AB-FUBINACA) [2.5gm - 0.107gm 5.00gm - 0.214gm] 2.5gm 5gm
Add
Pepe (Caffeine, proprietary blend, amino acids,black pepper extracts, vitamin B6) [50mg per gm]2.5gm
Add
POW (Sulfonylbismethane, green tea, guarana, cocoa, kigelia, taurine, citrus aurantium) [50mg per gm]2.5gm
Add
Puff Southern Lights (5F-PB-22) [50mg per gm]2.5gm
Add
Puff Super Strength (CL-2201) [50mg per gm]2.5gm
Add
PURE-GOE (Caffeine, hordeum vulgare extract, kava extract, citrus aurantium) [50mg per gm]2.5gm
Add
Radiation (PB-22) [50mg per gm]2.5gm
Add
Red X (PB-22) [50mg per gm]2.5gm
Add
SGT-24 (SGT-24) [50mg per gm]2.5gm
Add
Stargate (Tri-xanthine mix) [50mg per gm]2.5gm
Add
Tai High Afghan Kush (PB-22) [50mg per gm]2.5gm
Add
Tai High Black (PB-22) [50mg per gm]2.5gm
Add
Tai High Bubble Berry (AB-FUBINACA) [50mg per gm]2.5gm
Add
Tai High Code Red (PB-22) [50mg per gm]2.5gm
Add
Tai High Purple Passion (PB-22) [50mg per gm]2.5gm
Add
White Rhino (CP-55244) [50mg per gm]2.5gm
Add
WTF (PB-22) [50mg per gm]2.5gm
Add
XT (PB-22-F) [50mg per gm] 1.3gm 2gm
Add
Ziggy (AB-005) [50mg per gm]2.5gm
Add
Substance Name
Dose
Frequency
Route
Start Date
End Date
Add another substance
Add co-medications
Add a vaccination
Add nutritional supplement
Reaction
Onset date
Event Details
Duration of symptoms
Is the user dependent on the substance?
Yes
No
Have there been withdrawl symptoms?
Yes
No
Detox
Offered
Declined
Admitted
Outcome
Recovered
Not yet recovered but improved
Not yet recovered
Unknown
Severe
Yes
No
Fatal
Yes
No
Date of death
Attach files/images
Other Medical History
Does the patient have a history of mental health problems?
Yes
No
Unknown
Does the patient have, or ever had kidney problems?
Yes
No
Unknown
Does the patient have any allergies?
Yes
No
Unknown
Does the patient have liver problems?
Yes
No
Unknown
Does the patient have Other Medical Conditions?
Yes
No
Unknown
Reporter
Name
Profession
Phone
Address
Suburb
Town/City
Email
Remember me
Submit report