Infectious Disease Adverse Reaction Documentation Form
Patient Name
Patient ID
Date of Birth
Date of Reaction
Disease/Diagnosis
Medication / Vaccine
Dose / Lot Number
Description of Adverse Reaction
Onset Time (after exposure)
Severity
Mild
Moderate
Severe
Treatment Provided
Outcome
Recovered
Recovering
Not Recovered
Deceased
Reported By (Name/Title)
Date Reported