avn

VACCINE REACTION REPORT FORM

Name of Parent or Guardian (if reporting on behalf of a child)
Name of Person who reacted :
Date of Birth:
Date of First Reaction:
Street Address:
City : State:
Post Code:
Phone : Mobile:
Fax :
E-mail: URL :
NOTE: Names and addresses are confidential unless permission is given to share with media, government and solicitors who may be taking compensation cases on behalf of vaccine injured individuals in the future:

VACCINE HISTORY
Please list the dates that the following vaccines were administered:

Childhood & Adult Vaccines: 1st 2nd 3rd 4th
Diphtheria. Tetanus, Whole-Cell Pertussis (DPT)
Diphtheria, Tetanus, Acellular Pertussis (DPaT)
Childhood Diphteria, Tetanus, Acellular Pertissis (whooping cough), and Hep B
Diphtheria, HiB, Hepatitis B, Acellular Pertussis, Polio and Tetanus
Diphtheria, Hepatitis B, Acellular Pertussis, Polio and Tetanus
Childhood Diphtheria and Tetanus (CDT)
Diphtheria
Tetanus
Hepatitis A    
Hepatits B  
Hepatitis A and Hepatitis B  
HiB (Haemophilus Influenzae B)  
Childhood Influenza    
Cervical Cancer (HPV)  
Injected Polio
Oral Polio
Measles, Mumps and Rubella  
Rubella      
Meningococcal C (childhood)  
Pneumococcal (7-valent-children)  
Rotavirus  
Chicken Pox (Varicella)    
 
Adult Only Vaccines 1st 2nd 3rd 4th
Adult Diphtheria, Tetanus, Acellular Pertussis (whooping cought) (DPaT)
Adult Diphtheria and Tetanus (ADT)
Adult Influenza    
Japanese Encephalitis      
Meningococcal C (adult)  
Pneumococcal (23-valent-adult)      
Q-Fever Vaccine      
Rabies  
Yellow Fever      
Typhoid      
 
   
NOTE: It is important that you provide information that is as accurate as possible. We realise that it may have been some time since these reactions took place and therefore, if you do not have the exact dates the vaccines were administered, please provide us with the month and year or, if neccessary, just the year.

Were you or your child seen by a doctor at the time the vaccine was administered? N
Were you warned about the possibility of vaccine side effects or failures? Y N
Did you or your child have any symptoms of illness at the time? Y N
Please describe your symptoms    
Were you or your child on any medications at the time? Y N
Which ones?    
What was the date of the first reaction?: Batch Nos:
Was the vaccination names as the cause of illness by a doctor? Y N
Name and address of administering doctor/clinic:    
Was treatment prescribed for the reaction?
How much time had elapsed between the vaccination and the reaction?
Please describe the reaction:    
     
Did the person to whom this report relates develop any of the following ...(Please check box)
Persistent Crying -How Long?
Vomiting/Nausea Breathing Difficulties      
Convulsions/Seizures Encephalitis (infection of the central nervous system)
Change in bowel patterns Change in sleep patterns    
Fever above 38.5C Change in behaviour    
Screaming - How Long?
Loss of ability (e.g walking, sitting, speaking) other ...
Ear Pain Fainting/Loss of Consciousness    
Meningitis Death      
Skin Rash
Other
     
Please fill in the following section if reporting for a child:    

Was the birth normal?

 Y N
Ceaserian? Y N
Other?    
Was the child breastfed? Y N
For How Long?    
Did the child have any chronic health conditions (allergies, etc) before vaccination? Y N
Please describe:    
Did the child have any chronic health conditions after vaccination? Y N
Please describe:    
Has the person whose reaction is being reported contracted any diseases they were vaccinated against? Y N
Which Ones:    
Doctor Diagnosed? Y N
How Long After Vaccination?    
What is the present condition of the person for whom this report is being entered?    
If you would like to learn about any possible legal actions planned on behalf of vaccine victims, please tick  
If you feel you are able to share your story wit the media, please tick here  
If you would like to report this reaction to the government, please tick here  
     
   

The Australian Vaccination Network would like to thank you for taking the time to fill our this reaction report form.

 

Joomla Professional Work
Copyright © 2008, AVN Inc.
All Rights Reserved.
Privacy Policy|Legal Notice
http://avn.org.au/library, Powered by Joomla and Designed by Sarita
????????