Adverse Reactions Reports Form - British Nuclear Medicine Society

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Sat Jun 9th 2012
12:00am
SNM 59th Annual Meeting

Adverse Reactions Report Form

Date of Incident	Invalid Input
Age of Patient	Invalid Input
Gender of Patient	MaleFemale Invalid Input
Optional ID Number	Invalid Input
Isotope Generator Manufacturer	Invalid Input
Isotope Generator Product Name	Invalid Input
Isotope Generator Lot Label	Invalid Input
Radiopharmaceutical Manufacturer	Invalid Input
Radiopharmaceutical Product Name	Invalid Input
Radiopharmaceutical Lot Label	Invalid Input
Give brief details of materials, sources, preparation, storage	Invalid Input
Confirm the commercial manufacturers have been informed	YesNo Invalid Input
Clinical Diagnosis	Invalid Input
Nature of Reaction (timing, symptoms, clinical observations)	Invalid Input
Nature of Study	Invalid Input
Has the patient any known allergies?	Invalid Input
Severity of Reaction	Invalid Input
Probablilty of Association with Radiopharmaceuticals	Invalid Input
Treatment of the Reaction (drug and resucitative measures required)	Invalid Input
Other Medications (Current or Recently Taken)	Invalid Input
Your Name	Fullname must contain only a-z,A-Z characters
Title	Invalid Input
Email Address	Please add a valid e-mail address.
Department	Invalid Input
Address	Invalid Input
Telephone Number	Invalid Input
Fax Number	Invalid Input