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Patient Last name
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Patient First name
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Patient middle name
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Phone #
?
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Attending physician name
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Birth date
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{mm/dd/yyyy}
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Age
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a
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Sex
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Date form completed
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{mm/dd/yyyy}
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Vaccination AE
?
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Vaccination AE outcome VAERS
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# days hospitalized due to vacc AE
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d
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Patient recovered VAERS
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Date+time of vaccination
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Date+time onset of vaccine AE
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Relevant Dx tests/lab data
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Vaccines same date as vaccine causing AE
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Other vaccines given within 4W
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Vaccinated at VAERS
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Funds vaccine purchased with VAERS
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Other medications
?
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Illness at time of vaccination
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Pre-existing conditions
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AE previously reported VAERS
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AE p vaccine in patient
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AE p vaccine Brother
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AE p vaccine Sister
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# brothers and sisters
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{#}
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Creator report # VAERS
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Date received
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15 day report VAERS
?
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Type VAERS
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AE VAERS
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Type Vaccine
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Type Vaccine
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AE VAERS
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AE VAERS
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Age at onset of AE
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a
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Manufacturer name Vaccine
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Manufacturer name Vaccine
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Age at onset of AE
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a
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Age at onset of AE
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a
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Lot # Vaccine
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Dose #
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Dose #
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Dose #
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Lot # Vaccine
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Route Vaccine.administered
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Route Vaccine.administered
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Vaccination body site
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Vaccination body site
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# previous doses
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{#}
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# previous doses
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{#}
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