Patient
Surname
First names
Female  Male
DOB
NHI
Ethnicity
Town/City
Psychoactive & Recreational Substances
Substance Name
Dose
Frequency
Route
Start Date
End Date





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
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