Fiche CIOMS/ CIOMS form
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Fiche CIOMS/ CIOMS form

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Description

Drugs
29/08/2001

Subjects

Informations

Published by
Published 29 August 2001
Reads 106
Language English
 PATIENT DIED
 INVOLVED OR PROLONGED INPATIENT HOSPITALISATION
 INVOLVED PERSISTENCE OR SIGNIFICANT DISABILITY OR INCAPACITY
III. CONCOMITANT DRUG(S) AND HISTORY
18. THERAPY DATES (from/to)
17. INDICATION(S) FOR USE
15. DAILY DOSE(S)
22. CONCOMITANT DRUG(S) AND DATES OF ADMINISTRATION (exclude those used to treat reaction)
23. OTHER RELEVANT HISTORY (e;g; diagnostics, allergies, pregnancy with last month of period, etc. ...)
24c. DATE RECEIVED BY MANUFACTURER
DATE OF THIS REPORT
24d. REPORT SOURCE  STUDY LITERATURE  HEALTH PROFESSIONAL
25a. REPORT TYPE
 INITIAL FOLLOW-UP
Describe reaction (continuation) :
Year
Day
Month
Day Month
Year
I. REACTION INFORMATION
8 - 12 CHECK ALL APPROPRIATE TO ADVERSE REACTION
3. SEX
4 - 6 REACTION ONSET
2. DATE OF BIRTH
2a. AGE Years
1. PATIENT INITIAL
1a. COUNTRY
SUSPECT ADVERSE REACTION REPORT
CIOMS FORM*
Event :
14. SUSPECT DRUG(S) (including generic name)
19. THERAPY DURATION
7 - 13 DESCRIBE REACTION (S) (including test/lab data)
Comment :
Subsidiary Reference Number
24b. MFR CONTROL N°  
24a. NAME AND ADDRESS OF MANUFACTURER
IV. MANUFACTURER INFORMATION
 YES NO NA
16. ROUTE(S) OF ADMINISTRATION
II. SUSPECT DRUG(S) INFORMATION
Other references
 LIFE THREATENING
20. DID REACTION ABATE AFTER STOPPING DRUG ?
 YES NO NA
21. DID REACTION REAPPEAR AFTER REINTRODUCTION ?