HVC No__________________________

_________/__________
Spontaneous
Intensive (trigger tool)

HN __________ _________________________
_________ () _______ . __________________________________
________________________ : OPD ER Observe
_________________________ICD10__________________ : F1 F2 F3 F4 F5 F6 FPed OR LR

_____________________________________________________
______ / _____ / _____
Type A (S/E) Type B (Allergy) Other_________
(S)

Onset
ICD10
1.
______.
2.
______.
3.
______.
(O) ( ) 3 6
1.
2.
3.
4.
(, )__________________________________________________

()
1. [ ] [ ] [ ]
2. Serious Adverse Event [ ] [ ] ( Serious Adverse Event )
( _____/______/______)

3. [ ] [ ] () ____________________________________________________
4. [ ] [ ] [ ]
5. [ ] [ ] [ ]
/

. / . ______________________

____ / ______ / _______

[ ] Certain [ ] Probable [ ] Possible [ ] Unlikely [ ] Unclassified

. . 038 411551 115
ADRprofile 3.1