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CIOMS FORM SUSPECT ADVERSE REACTION REPORT I. REACTION INFORMATICN 1. PATIENT INITIALS 1a. COUNTRY 2. DATE OF BIRTH 2a. AGE 3. SEX 3a. WEIGHT 4-6 REACTION ONSET (first. last) |ta|y Day Month Year 65 Unk Day Month Year PRIVACY PRIVACl Y Years |Female 18 | NOV [2021 7 + 13 DESCRIBE REACTION(S) (including relevant tests/l... | Scanned_CIOMS_ocred.pdf |
Page 2 of 3 Mfr. Control Number: NVSC2022IT011983 ADDITIONAL INFORMATION 7+13. DESCRIBE REACTION(S) continued The subject's historical conditions included rib fracture (from 12 Feb 2021), pyelocystitis (from 2000}, pneumonitis (from 2000) and erysipelas (from 2019). Current conditions included rib fracture, basedow dis... | Scanned_CIOMS_ocred.pdf |
Page 3 of 3 Mfr. Control Number: NVSC2022IT011983 ADDITIONAL INFORMATION 23. OTHER RELEVANT HISTORY continued From/To Dates Type of History / Notes Description 2000 to Unknown Historical Condition Pneumonitis (Pneumonitis); 2002 to Ongoing Current Condition Mitral valve disease (Mitral valve disease); 2019 to Unknown H... | Scanned_CIOMS_ocred.pdf |
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