Date:

CoViD-19 Coronavac Lot #

Adverse Event Following Immunization AZD 1222 Lot #
Directions: Use blue ballpen to fill the data. √ for the symptoms if present. X if absent.
Name: Contact Number:
In case of emergency, proceed to MPH Emergency Room or call HEMS hotline: 09109194128 / 09382775443
If positive for any post-immunization reactions, text or call the MPH Surveillance Officer: 09206987996
ADVERSE EVENT following Immunization 5” 10” 15” 20” 25” 30” 45” 60” DISPOSITION (check)
1. Tenderness on injection site (pananakit ng pinagturukan) To ER NOW
2. Erythema on injection site (pamumula ng pinagturukan) Discharged Unremarkable
3. Induration (pamamaga ng pinagturukan) DAMA
4. Rashes/hives Abscond
5. Wheals (pamamantal/”labak”) Died
6. Urticaria (pangangati/”pangatol”) REMARKS
7. Warm sensation (mainit sa pakiramdam)
8. Fever
9. Chills
10. Myalgia (pananakit ng kalamnan)
11. Arthralgia (pananakit ng kasu-kasuan)
12. Headache
13. Nausea (nasusuka, nahihilo)
14. Vomiting (nagsuka)
15. Wheezing
16. Dyspnea (nahihirapan sa paghinga)
ADVERSE EVENT of Special Interest
1. Enhanced Disease ff immunization
2. Cytokine Release Syndrome
3. Acute Respiratory Distress Syndrome
4. Acute Cardiac Injury
5. Coagulation Disorder
6. Acute Kidney Injury
7. Liver Injury
8. Guillain-Barre syndrome Signature over printed name

9. Anosmia, Ageusia, Meningoencephalitis

10. Childblain-like lesions, Cutaneous RN
Vasculitis, Erythema Multiforme Adverse Event Monitor
 Day After
ADVERSE EVENT following Month/s After Immunization
Imm.
Immunization 14 28 1 2 3 4 5 6 7 8 9 10 11 12
DATE
1. Tenderness on injection site (pananakit ng
pinagturukan)
2. Erythema on injection site (pamumula ng
pinagturukan)
3. Induration (pamamaga ng
pinagturukan)
4. Rashes/hives
5. Wheals (pamamantal/”labak”)
6. Urticaria (pangangati/”pangatol”)
7. Warm sensation (mainit sa
pakiramdam)
8. Fever
9. Chills
10. Myalgia (pananakit ng kalamnan)
11. Arthralgia (pananakit ng kasu-
kasuan)
12. Headache
13. Nausea (nasusuka, nahihilo)
14. Vomiting (nagsuka)
15. Wheezing
16. Dyspnea (nahihirapan sa paghinga)
ADVERSE EVENT of Special Interest
1. Enhanced Disease ff immunization
2. Cytokine Release Syndrome
3. Acute Respiratory Distress Syndrome
4. Acute Cardiac Injury
5. Coagulation Disorder
6. Acute Kidney Injury
7. Liver Injury
8. Guillain-Barre syndrome
9. Anosmia, Ageusia,
Meningoencephalitis
10. Childblain-like lesions, Cutaneous
Vasculitis, Erythema Multiforme