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Get Au Tga D1073 2015-2024

S form Patient initials or medical record number: Sex: M Date of birth or age: F Weight (kg): Suspected medicine(s)/vaccine(s) Dosage Medicine/vaccine (Dose number for vaccines eg 1st DTP) (please use trade names; include batch number and AUST R or AUST L number if known) Date begun Date stopped Reason for use Other medicine(s)/vaccine(s) taken at the time of the reaction Dosage Medicine/vaccine Reaction(s): Date begun Date stopped Reason for use Date of onset of reaction (for.

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