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Confidentiality information for reporters
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Patient
Female  Male
Surname
First names
DOB
NHI
Ethnicity
Weight
Address
Suburb
Town/City
Is this an adverse event following immunisation
Medications
Suspect Yes No
Medicine Name
Dose
Route
Frequency
Reason for use
Start Date
End Date



Reaction
Onset date
Details *
Have COVID-19 circumstances contributed to this event? Yes    No    Unknown
Outcome
Recovered
Not yet recovered but improved
Not yet recovered
Unknown
Severe
Yes
No
Rechallenge
Yes
No
Rechall. result
Fatal
Yes
No
Date of death
Add attachments (files, images etc) - PLEASE WAIT FOR THE UPLOAD TO COMPLETE - It will say "filename.pdf - Completed"
Other Factors
Does the patient have, or ever had kidney problems?
Yes    No    Unknown
Does the patient have any allergies?
Yes    No    Unknown
Does the patient have liver problems?
Yes    No    Unknown
Does the patient have Other Medical Conditions?
Yes    No    Unknown
Does the patient take Alternative Medicines?
Yes    No    Unknown
Does the patient take Nutritional Supplements?
Yes    No    Unknown
Does the patient take "Over the Counter" Medicines?
Yes    No    Unknown
Does the patient work with Industrial chemicals?
Yes    No    Unknown
Reporter
Name
Profession
Phone
Name of Workplace
Work Postal Address
Suburb
Town/City
Postcode
Email
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