| 45394-4 | Patient Last name | |
| 45392-8 | Patient First name | |
| 52461-1 | Patient middle name | |
| 42077-8 | Phone # | |
| 52526-1 | Attending physician name | |
| 21112-8 | Birth date | |
| 30525-0 | Age | |
| 46098-0 | Sex | |
| 30947-6 | Date form completed | |
| 30948-4 | Vaccination AE | |
| 30949-2 | Vaccination AE outcome VAERS | |
| 30950-0 | # days hospitalized due to vacc AE | |
| 30951-8 | Patient recovered VAERS | |
| 30952-6 | Date+time of vaccination | |
| 30953-4 | Date+time onset of vaccine AE | |
| 30954-2 | Relevant dx tests/lab data note | |
| 30955-9 | Vaccines same date as vaccine causing AE | |
| 30961-7 | Other vaccines given within 4W | |
| 30962-5 | Vaccinated at VAERS | |
| 30963-3 | Funds vaccine purchased with VAERS | |
| 30964-1 | Other medications | |
| 30965-8 | Illness at time of vaccination | |
| 30966-6 | Pre-existing conditions | |
| 30967-4 | AE previously reported VAERS | |
| 30968-2 | AE p vaccine in patient | |
| 30969-0 | AE p vaccine Brother | |
| 30970-8 | AE p vaccine Sister | |
| 30974-0 | # brothers and sisters | |
| 30975-7 | Creator report # VAERS | |
| 30976-5 | Date received | |
| 30977-3 | 15 day report VAERS | |
| 30978-1 | Type VAERS | |
| 55140-8 | VAERS Pnl | |