Patient name: Age:
Sex: M/F Consultant: Dept/Unit: UHID:
Information for patient:
● Disulfiram is a medication that is used to help prevent relapse to alcohol.
● The body is not able to process alcohol while taking disulfiram. This includes even very small
doses that may be absorbed from perfume/deodorant, hand sanitizer, mouth washes, gargles, tonics, ayurvedic/homeopathic medicines, food items (dressings, vinegars, marinades, sauces, extracts, etc.) and alcoholic beverages. It is important to check labels of items that will go in or on your body.
● Disulfiram should NOT be taken if you have consumed alcohol within the past 12 hours.
● A disulfiram-alcohol reaction may include: trouble breathing, throbbing pain in head and neck,
nausea, vomiting, sweating, thirst, palpitations, weakness, dizziness, blurred vision, and confusion. Severe reactions may involve respiratory failure, heart failure, unconsciousness, seizure, and death.
● The larger the dose of the alcohol, the stronger the disulfiram-alcohol effect. The reaction can last from 30 minutes to several hours, or as long as it takes for the alcohol to be metabolized.
● Disulfiram-alcohol reaction may occur for up to 2 weeks after stopping medication.
● Allergic reactions can happen when taking disulfiram. Alert your treatment team or get immediate
medical help if you have any of these symptoms:
● Skin rash
● Chest pain
● Trouble breathing or wheezing
● Dizziness or fainting
● Swelling of eyes, mouth, tongue, or face
● The most common side effect of disulfiram is drowsiness, but severe adverse reactions have occurred in some individuals. These include: liver failure, nerve irritation/ neuropathy, psychosis, acne, skin rash, impotence, and inflammation of the optic nerve.
● There are some medications that should not be taken with disulfiram (metronidazole, certain cough medicines, others). It is important to let your providers know that you are prescribed disulfiram. Do not change your medications without checking with your provider.
● Relapse to alcohol is very dangerous after being on disulfiram. Alert your family, friends, and close contacts that you are on disulfiram and about the risk of a severe reactions should you have a relapse.
● I consent to starting disulfiram treatment.
● I acknowledge the psychiatrist has informed me about disulfiram, available alternative treatments
and answered my specific queries and concerns about this treatment.
● I acknowledge that I have discussed with the psychiatrist any significant risks and complications
specific to my personal circumstances and I have considered these in deciding to have this treatment.

● I have not been guaranteed the treatment will be successful, and I understand the treatment is not a long-term cure for the condition, so I may relapse in the future.
● Having understood the above I give my consent and absolve Yenepoya Medical College Hospital, Mangalore, its doctors and the staff in the event of any complication.
Patient’s full name
Patient’s signature
Witness name and signature : Carer’s name and signature: Relationship to the patient:
Date and time: Date and time:

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