CIOMS FORM
I. REACTION INFORMATION
SUSPECT ADVERSE REACTION REPORT
1. PATIENT INITIALS
1a. COUNTRY
2a. AGE
3. SEX
Day
Year
Day
nd过去式Month
8-12 CHECK ALL烙饼的做法
(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
INVOLVED OR
PROLONGED INPATIENT HOSPITALISATION
第八套广播体操视频完整版
LIFE
THREATENING
雷蛇鼠标怎么拆
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)
15. DAILY DOSE(S)
16. ROUTE(S) OF ADMINISTRATION
17. INDICATION(S) FOR USE
19. THERAPY DURATION
18. THERAPY DATES (from/to)
兔子图画
YES
ABATE AFTER STOPPING DRUG?大红鱼
II. SUSPECT DRUG(S) INFORMATION
NO
NA
REAPPEAR AFTER REINTRODUCTION?
紫云烟
NO
NA
YES
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
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:
四楼的英文
HEALTH
PROFESSIONAL
25a. REPORT TYPE
