Reporter Details

Patient Details

E-Liquid Details

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Side Effects Details

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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) Please select at least one option

Additional 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).