Case Series Drug Analysis Print Name: Vaxigrip, Fluarix, Inflexal V og Influenzacvaccine 01Sep Oct2014
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1 - 16Oct2014 Report Run Date: 20-Oct-2014 Data Lock Date: 16-Oct :00:06 Earliest Reaction Date: 28-Oct-2009 MedDRA Version: MedDRA 17.0 Vaxigrip, Fluarix, Inflexal V og Influenzacvaccine : Alle cases for Vaxigrip, Fluarix, Inflexal V og Influenzavaccination pr. og frem Report Run Date: 20-Oct-2014, Page 1
2 Blood disorders Lymphatic system disorders NEC Lymphadenopathy 1 0 Thrombocytopenias Thrombotic thrombocytopenic purpura 1 0 Blood disorders SOC TOTAL 2 0 Report Run Date: 20-Oct-2014, Page 2
3 Cardiac disorders Cardiac disorders NEC Cardiac disorder 1 0 Cardiac signs and symptoms NEC Palpitations 1 0 Ischaemic coronary artery disorders Angina pectoris 1 0 Noninfectious pericarditis Pericarditis 1 0 Cardiac disorders SOC TOTAL 4 0 Report Run Date: 20-Oct-2014, Page 3
4 Ear disorders Ear disorders NEC Ear swelling 1 0 Hearing losses Hearing impaired 1 0 Hyperacusia Hyperacusis 2 0 Inner ear signs and symptoms Tinnitus 3 0 Vertigo 1 0 Ear disorders SOC TOTAL 8 0 Report Run Date: 20-Oct-2014, Page 4
5 Eye disorders Lacrimation disorders Dry eye 1 0 Lid, lash and lacrimal infections, irritations and inflammations Eyelid oedema 1 0 Ocular disorders NEC Eye disorder 1 0 Eye swelling 1 0 Ocular infections, inflammations and associated manifestations Ocular hyperaemia 1 0 Ocular sensation disorders Photophobia 1 0 Visual disorders NEC Visual impairment 1 0 Eye disorders SOC TOTAL 7 0 Report Run Date: 20-Oct-2014, Page 5
6 Gastrointestinal disorders Gastrointestinal and abdominal pains (excl oral and throat) Abdominal pain 1 0 Abdominal pain upper 1 0 Nausea and vomiting symptoms Nausea 3 0 Vomiting 1 0 Oral soft tissue pain and paraesthesia Paraesthesia oral 1 0 Oral soft tissue signs and symptoms Burning mouth syndrome 1 0 Hypoaesthesia oral 1 0 Oral discomfort 1 0 Oral soft tissue swelling and oedema Lip swelling 1 0 Oedema mouth 1 0 Gastrointestinal disorders SOC TOTAL 12 0 Report Run Date: 20-Oct-2014, Page 6
7 General disorders Asthenic conditions Asthenia 2 0 Fatigue 8 0 Malaise 6 0 Death and sudden death Death 1 1 Febrile disorders Pyrexia 4 0 Feelings and sensations NEC Chills 1 0 Feeling abnormal 2 0 Feeling cold 1 0 General signs and symptoms NEC Influenza like illness 6 0 Local reaction 1 0 Local swelling 1 0 Injection site reactions Injection site erythema 4 0 Injection site joint movement impairment 1 0 Injection site pain 1 0 Injection site swelling 1 0 Oedema NEC Oedema 1 0 Oedema peripheral 1 0 Pain and discomfort NEC Discomfort 1 0 Pain 2 0 Tenderness 2 0 Vaccination site reactions Vaccination site pain 1 0 General disorders SOC TOTAL 48 1 Report Run Date: 20-Oct-2014, Page 7
8 Immune system disorders Allergic conditions NEC Hypersensitivity 2 0 Anaphylactic responses Anaphylactic reaction 1 0 Anaphylactic shock 1 0 Immune and associated conditions NEC Multiple chemical sensitivity 1 0 Immune system disorders SOC TOTAL 5 0 Report Run Date: 20-Oct-2014, Page 8
9 Infections Bacterial infections NEC Pneumonia bacterial 1 0 Herpes viral infections Herpes simplex 2 0 Influenza viral infections Influenza 1 0 Lower respiratory tract and lung infections Atypical pneumonia 1 0 Upper respiratory tract infections Pharyngitis 1 0 Viral infections NEC Post viral fatigue syndrome 1 0 Infections SOC TOTAL 7 0 Report Run Date: 20-Oct-2014, Page 9
10 Investigations Heart rate and pulse investigations Heart rate increased 1 0 Physical examination procedures and organ system status Weight decreased 1 0 Investigations SOC TOTAL 2 0 Report Run Date: 20-Oct-2014, Page 10
11 Metabolic disorders Food malabsorption and intolerance syndromes (excl sugar intolerance) Food intolerance 1 0 Metabolic disorders SOC TOTAL 1 0 Report Run Date: 20-Oct-2014, Page 11
12 Muscle & tissue disorders Arthropathies NEC Arthritis 1 0 Connective tissue disorders NEC Polymyalgia rheumatica 2 0 Joint related disorders NEC Periarthritis 1 0 Rotator cuff syndrome 1 0 Joint related signs and symptoms Arthralgia 7 0 Joint stiffness 1 0 Muscle pains Myalgia 5 0 Muscle related signs and symptoms NEC Muscle spasms 2 0 Musculoskeletal and connective tissue pain and discomfort Back pain 1 0 Musculoskeletal pain 2 0 Neck pain 1 0 Pain in extremity 2 0 Muscle & tissue disorders SOC TOTAL 26 0 Report Run Date: 20-Oct-2014, Page 12
13 Nervous system disorders Acute polyneuropathies Guillain-Barre syndrome 1 0 Polyneuropathy 1 0 Coordination and balance disturbances Balance disorder 2 0 Dyskinesias and movement disorders NEC Dyskinesia 1 0 Movement disorder 1 0 Facial cranial nerve disorders VIIth nerve paralysis 1 0 Headaches NEC Headache 5 0 Memory loss (excl dementia) Memory impairment 3 0 Mental impairment (excl dementia and memory loss) Cognitive disorder 1 0 Disturbance in attention 1 0 Migraine headaches Migraine 1 0 Mononeuropathies Peroneal nerve palsy 1 0 Narcolepsy and hypersomnia Hypersomnia 1 0 Neurological signs and symptoms NEC Dizziness 4 0 Presyncope 1 0 Paraesthesias and dysaesthesias Paraesthesia 4 0 Paralysis and paresis (excl cranial nerve) Paralysis 1 0 Sensory abnormalities NEC Dysgeusia 1 0 Neuralgia 2 0 Sensory disturbance 1 0 Tremor (excl congenital) Tremor 1 0 Nervous system disorders SOC TOTAL 35 0 Report Run Date: 20-Oct-2014, Page 13
14 Psychiatric disorders Disturbances in initiating and maintaining sleep Insomnia 1 0 Eating disorders NEC Eating disorder 1 0 Psychiatric disorders SOC TOTAL 2 0 Report Run Date: 20-Oct-2014, Page 14
15 Respiratory disorders Breathing abnormalities Dyspnoea 3 0 Upper respiratory tract signs and symptoms Dysphonia 1 0 Respiratory disorders SOC TOTAL 4 0 Report Run Date: 20-Oct-2014, Page 15
16 Skin disorders Angioedemas Angioedema 1 0 Swelling face 1 0 Apocrine and eccrine gland disorders Hyperhidrosis 2 0 Dermatitis and eczema Dermatitis 1 0 Erythemas Erythema 3 0 Rash erythematous 1 0 Pruritus NEC Pruritus 4 0 Purpura and related conditions Henoch-Schonlein purpura 1 0 Rashes, eruptions and exanthems NEC Rash 5 0 Skin hyperplasias and hypertrophies Skin hypertrophy 1 0 Urticarias Urticaria 4 0 Skin disorders SOC TOTAL 24 0 Report Run Date: 20-Oct-2014, Page 16
17 Social circumstances Disability issues Walking disability 1 0 Social circumstances SOC TOTAL 1 0 Report Run Date: 20-Oct-2014, Page 17
18 Vascular disorders Vascular hypertensive disorders NEC Hypertension 2 0 Vascular hypotensive disorders Orthostatic hypotension 1 0 Vascular disorders SOC TOTAL 3 0 TOTAL REACTIONS FOR DRUG TOTAL REPORTS 46 TOTAL FATAL OUTCOME REPORTS 1 Report Run Date: 20-Oct-2014, Page 18
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!1 Headache Follow-up Visit Form We will be unable to see you unless this form is completely filled out. We appreciate your thoroughness. Name DOB Age Today s Date Referring doctor: Primary doctor: Neurologist:
The Premier Vein Center Evan Oblonsky MD 1051 W. Rand Road, Suite 104 Arlington Heights, IL Tel: Fax:
PATIENT INFORMATION (PLEASE PRINT) Patient Name: Nickname: Guardian: Date of Birth: Sex: Address: 2nd Address: Home Phone: Work Phone: Cell Phone: Best Number: License / ID# Contact Email: Emergency Contact:
DOB: / / Please list the names and telephone numbers of the other physicians involved in your care: Name Specialty Phone Address Receive Report (Y/N)
Medical History: Patient: DOB: / / Please list the names and telephone numbers of the other physicians involved in your care: Name Specialty Phone Address Receive Report (Y/N) List the names of prescription
U.S. Department of Health and Human Services Food and Drug Administration Center for Food Safety and Applied Nutrition
U.S. Department of Health and Human Services Food and Drug Administration Center for Food Safety and Applied Nutrition CFSAN Adverse Event Reporting System Voluntary and Mandatory Reports on 5-Hour Energy,
PERSONAL MEDICAL AND FAMILY HISTORY Please check applicable boxes.
Name: DOB: PERSONAL MEDICAL AND FAMILY HISTORY Please check applicable boxes. TOBACCO USE: Quit Date Cigarettes Packs/Day Number of years smoked Pipe/Cigar Smokeless Tobacco Electronic or E-cigarette Secondhand
0BCore Safety Profile
0BCore Safety Profile Active substance: Iodixanol Pharmaceutical form(s)/strength: 270 mg I/ml Solution for Injection 20 /50 / 100 /200 / 500 ml; 320 mg I/ml Solution for Injection 20 /50 / 100 /200 /
Pain Management Questionnaire
In order to make the most of your visit, we require this form to be completed to the best of your ability and sent to the Pain Management Clinic a copy should be shared with your Primary Care Provider
Caspian Acupuncture -- Health History Form Anita Tayyebi EAMP, LAc. 652 SW 150 th St Burien WA 98166
Frist Name Last: Date Phone (H) (C) (W) E-mail Address City State Zip Age DOB Place of Birth _ Marital/Partnership Status Preferred Gender Pronoun _ Profession Family Physician Telephone # Referred By
Initial Consultation
Today s Date: Initial Consultation Thank you for choosing Apollo Health and Wellness. Please take your time to fill out this form. It will help us to concentrate on areas of your health that need attention
Charles Khouri, PharmD; Marion Lepelley, PharmD; Matthieu Roustit, PharmD; François Montastruc, MD; Marc Humbert, MD; and Jean-Luc Cracowski, MD
Online Supplement Comparative Safety of Drugs Targeting the Nitric Oxide Pathway in Pulmonary Hypertension A Mixed Approach Combining a Meta-Analysis of Clinical Trials and a Disproportionality Analysis
CENTRAL CARE POLICY SYMPTOMS OF ILLNESS. Policy: Consumers will be observed for symptoms of physical problems, distress, pain, or unusual behaviors.
Page 1 of 5 CENTRAL CARE POLICY SYMPTOMS OF ILLNESS SUBJECT: SYMPTOMS OF ILLNESS ANNUAL REVIEW MONTH: June RESPONSIBLE FOR REVIEW: Director of Central Care LAST REVISION DATE: June 2009 Policy: Consumers
PATIENT HEALTH QUESTIONNAIRE Radiation Oncology
REVIEWED DATE / INITIALS Safety: Are you at risk for falls? Do you have a Pacemaker? Females; Is there a possibility you may be pregnant? Allergies: If YES, please list medication allergies: Do you have
Study No.: Title: Rationale: Phase: Study Period: Study Design: Centres: Indication: Treatment: Objectives: Primary Outcome/Efficacy Variable:
The study listed may include approved and non-approved uses, formulations or treatment regimens. The results reported in any single study may not reflect the overall results obtained on studies of a product.
PACKAGE LEAFLET: INFORMATION FOR THE PATIENT. UROMITEXAN 400 mg and 600 mg Tablets Mesna
PACKAGE LEAFLET: INFORMATION FOR THE PATIENT UROMITEXAN 400 mg and 600 mg Tablets Mesna Read all of this leaflet carefully before you are given this medicine because it contains important information for
PATIENT INFORMATION LEAFLET DYNARB RANGE
SCHEDULING STATUS: S3 PROPRIETARY NAME, STRENGTH AND PHARMACEUTICAL FORM: DYNARB 75 mg tablets DYNARB 150 mg tablets DYNARB 300 mg tablets Read all of this leaflet carefully before you start taking DYNARB.
Sponsor Novartis. Generic Drug Name Pasireotide. Therapeutic Area of Trial Cushing s disease. Protocol Number CSOM230B2208E1
Sponsor Novartis Generic Drug Name Pasireotide Therapeutic Area of Trial Cushing s disease Protocol Number CSOM230B2208E1 Title Extension to a multicenter, open-label study to assess the safety and efficacy