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