Spreadsheet: 158469d1338276152-adding-rows-with-macros-without-ruining-other-macro-references-help-adding-rows
Sheet: Astellas Adverse Event Form

 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Prograf | 0.5 milligram capsule by mouth | 5 milligram tablet by mouth | 30 gram tube administered topically | 0.4 milligrams per 5 milliliters injection by intravenous administration | 60 milligram per 20 milliliter in a 20 milliliter injection by intravenous infusion | 20 milligram injection by intravenous infusion | 50 milligram injection by intravenous infusion | 50 milligram injection by intravenous infusion
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | VESIcare | 1 milligram capsule by mouth | 10 milligram tablet by mouth | 60 gram tube administered topically |  | 90 milligram per 20 milliliter in a 30 milliliter injection by intravenous infusion |  | 100 milligram injection by intravenous infusion
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Protopic | 5 milligram capsule by mouth
 | Consultant Name |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Date Information Received |  |  |  |  |  |  |  |  |  |  | 2012-05-29 00:00:00 |  |  |  |  |  | Reference ID: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Lexiscan
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Adenoscan
 | Reporter Information |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Patient Information |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | [NAME]
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Mycamine
 | Name: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Name: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | AmBisome
 | Street Address: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Street Address:
 | City, State: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | City, State:
 | Zip Code: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Zip Code:
 | Telephone: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Telephone:
 | Fax: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Fax:
 | Relationship to Patient: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | [NAME]:
 | Provider Information |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Date of Birth: |  |  |  |  |  |  |  |  |  | Age at onset:
 | Name: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Weight:
 | Facility Name: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Height:
 | Facility Street Address: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Pregnant:
 | City, State: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Company Rep contact information (if applicable)
 | Zip Code: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Name:
 | Telephone: |  |  |  |  |  |  |  |  |  |  | Fax: |  |  |  |  |  |  |  |  |  |  |  | Contact Information:
 | [NAME]: |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Date Company Rep Received Information:
 | Patient Relevant Medical History
 | Food/Drug Allergies:
 | Other (Alcohol/Tobacco/Family):
 | Occupational/Environmental History:
 | Medical History Description (include date indication first began, date indication first diagnosed and previous treatment for indication)
 | Astellas Drug Information
 | Medication |  |  |  |  | Strength / Form / Route |  |  |  |  |  |  |  |  |  |  |  |  |  |  | Indication for Use |  |  |  |  |  |  |  |  |  | Dose / Frequency |  |  |  |  |  |  |  | Dates / Length of Use
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | -
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | -
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | -
 | Concomitant Medication Information
 | Medication |  |  |  |  |  |  |  |  |  | Strength / Form / Route |  |  |  |  |  |  |  |  |  | Indication for Use |  |  |  |  |  |  |  |  |  | Dose / Frequency |  |  |  |  |  |  |  | Dates / Length of Use
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | - |  |  |  |  |  |  |  |  |  |  | 0 | 0 |  |  |  |  |  |  |  |  |  |  | abcd | abcd
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | - |  |  |  |  |  |  |  |  |  |  | 0 | 0 |  |  |  |  |  |  |  |  |  |  | abcd | abcd
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | - |  |  |  |  |  |  |  |  |  |  | 0 | 0 |  |  |  |  |  |  |  |  |  |  | abcd | abcd
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | - |  |  |  |  |  |  |  |  |  |  | 0 | 0 |  |  |  |  |  |  |  |  |  |  | abcd | abcd
 | Event Information
 | Event term verbatim |  |  |  |  |  |  |  |  |  | Onset Date |  |  |  |  |  |  |  |  |  | Treatment for Event |  |  |  |  |  |  |  |  |  | Event Outcome* |  |  |  |  |  |  |  | Stop Date (if resolved)
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 0 | 0 |  |  |  |  |  |  |  |  |  |  | abcd | abcd
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 0 | 0 |  |  |  |  |  |  |  |  |  |  | abcd | abcd
 |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  | 0 | 0 |  |  |  |  |  |  |  |  |  |  | abcd | abcd
 | * Outcome terms (one for each event): Recovered, Recovering, Not recovered, Recovered with sequelae, Death, Unknown
 | Additional Information: NA
 | Relevant Laboratory Information
 | Test name |  |  |  |  |  |  |  |  |  | Date |  |  |  |  |  |  |  |  |  | Results (include units) |  |  |  |  |  |  |  |  |  |  |  |  |  | Lab Normal Values (include units)
 | Follow-up:
 | Consumer agrees to additional follow-up:
 | Consumer agrees to additional follow-up with HCP:
 | Refund request addressed:
 | Comment(s): |  |  |  |  | NA
 |  |  | Fax completed form within 24 hours to APGD US PSP at [PHONE] or email to  [EMAIL]