CIOMS FORM
I. REACTION INFORMATION
SUSPECT ADVERSE REACTION REPORT
1. PATIENT INITIALS
1a. COUNTRY
成人奶妈日记2a. AGE
3. SEX
Day
Year
Day
Month
8-12 CHECK ALL
(first, last)
3a. WEIGHT
4-6 REACTION ONSET 2. DATE OF BIRTH Month
Year
APPROPRIATE TO ADVERSE REACTION
INVOLVED PERSISTENT OR SIGNIFICANT DISABILITY OR INCAPACITY
信纸格式INVOLVED OR
PROLONGED INPATIENT HOSPITALISATION
LIFE
藏香不可以乱用THREATENING
PATIENT DIED
7 + 13 DESCRIBE REACTION(S) (including relevant tests/lab data)
Event Verbatim [PREFERRED TERM] (Related symptoms if any parated by commas)
14. SUSPECT DRUG(S) (include generic name)
eyesore
15. DAILY DOSE(S)
16. ROUTE(S) OF ADMINISTRATION
17. INDICATION(S) FOR USE
19. THERAPY DURATION
18. THERAPY DATES (from/to)
YES
ABATE AFTER STOPPING DRUG?
II. SUSPECT DRUG(S) INFORMATION
NO
张伟健
NA
REAPPEAR AFTER REINTRODUCTION?泡椒的做法
NO
NA
YES
如何卸载360安全卫士20. DID REACTION
21. DID REACTION
22. CONCOMITANT DRUG(S) AND DATES OF ADMINISTRATION (exclude tho ud to treat reaction)
III. CONCOMITANT DRUG(S) AND HISTORY
23. OTHER RELEVANT HISTORY (e.g. diagnostics, allergics, pregnancy with last month of period, etc.)
From/To Dates养鱼的好处
Type of History / Notes Description 24a. NAME AND ADDRESS OF MANUFACTURER
IV. MANUFACTURER INFORMATION
26. REMARKS
24b. MFR CONTROL NO.
24d. REPORT SOURCE
DATE OF THIS REPORT
24c.BY MANUFACTURER
INITIAL FOLLOWUP:
STUDY
DATE RECEIVED
LITERATURE 25b. NAME AND ADDRESS OF REPORTER
OTHER:
HEALTH
PROFESSIONAL
25a. REPORT TYPE
