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HPV VACCINE ADVERSE REACTION REPORT

Patient's Basic Information:    Male Female ID Number   
Name   Chart No   
Guardian   Phone （）
Date of Birth  YearMonthDay
Address  
Injection Center Information
Name of Injection Center   Contact Number （）
Medical Staff  
Address  
Adverse Reaction
Time  YearMonthDayHourMinute
Company of Medication MSD       GSK
Injection Times

Initial Injection  

       YearMonthDayHourMinute

Second Injection

       YearMonthDayHourMinute

Third Injection 

       YearMonthDayHourMinute
Details Of Adverse Reactions Fever：Degree Celcius.

   YearMonthDayHourMinute

Pregnancy：

   YearMonthDay， currently at       week

Allergy：                                              

Description at injection site：                                      

Abnormal Pap smear history：YearMonthDay

Abnormal HPV test history：YearMonthDay

Others：                                              

　
Management

Practice of Managing：

　

　

Medication：

     1.Name of medicine：                                        

     2.Dosage：                                        

Return Home for obserration .

Hospitalized Home for obserration：

     YearMonthDay  Attending physician

Referral：

1. Referral Hospital：

2. Referral Department：
Hospital  
Date of Report  YearMonthDayHourMinute