If under 18 years old, Name of Parent or Guardian:
Street Address: City: State: Postcode: Telephone Number: Email Address:
Vaccine/s administered prior to reaction: Date:
Batch number/s of the vaccine/s:
Please describe the reaction.
Did the person experiencing the reaction develop any of the following within 30 days of vaccination? (please tick where appropriate) Swelling at injection site Fever Skin rash Vomiting / Nausea Screaming (for how long?) Persistent crying (for how long?) Convulsions / Seizure Ear pain Breathing difficulties Change in bowel patterns Meningitis Encephalitis Shock / Collapse Death
Were you or your child seen by a doctor at the time the vaccine was administered? Yes No
Were you warned about the possibility of vaccine side-effects or failure? Yes No
Did the person who experienced the reaction have any symptoms of illness at the time? Yes No if Yes: Please describe symptoms.
Was the person on any medications at the time? Yes No if Yes: Please name.
Was vaccination named as the cause of illness by the doctor? Yes No
Name and adress of administering doctor / clinic:
What treatment was prescribed for the reaction?
List the dates that vaccines were administered (please try to be as accurate as possible. If it is difficult to recall exact dates the month and year, or just year, will suffice)
DTP: 1st: 2nd: 3rd: 4th: 5th: DTPa: 1st: 2nd: 3rd: 4th: 5th: Polio (oral): 1st: 2nd: 3rd: 4th: 5th: Polio (injected): 1st: 2nd: 3rd: 4th: 5th: Hepatitis B: 1st: 2nd: 3rd: Hib: 1st: 2nd: 3rd: Pneumococcal: 1st: 2nd: 3rd: MMR: 1st: 2nd: 3nd: Meningococcal: 1st: 2nd: 3rd: Chicken Pox: 1st: 2nd: 3rd: HPV: 1st: 2nd: 3rd: Rotavirus: 1st: 2nd: 3rd: Q Fever: 1st: Vitamin K: oral injection Influenza: (please note all dates vaccination received) Any other vaccines (please specify):
Was the birth normal? Yes No Caesarian Induced Other intervention?
Was the child breastfed? Yes No if Yes: For how long?
Did the child have any chronic health conditions (e.g. allergies) before vaccination? Yes No if Yes: Please describe.
Did the child have any chronic health conditions after vaccination? Yes No if Yes: Please describe.
If the child died, was the death reported as SIDS? Yes No
Did the child ever contract any of the diseases they were vaccinated against? Yes No if Yes: Which one/s? Diagnosed by doctor? Yes No if Yes: How long after the vaccination?
If a vaccinated child contracted the disease, did they pass it on to anyone else? Yes No
What is the present condition of the child for whom this report is being entered?
The AVN would like to thank you for taking the time to fill out this reaction report.
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