OPALIA RECORDATI S.A - Tunisia

Formulaire

Treated patient

Step 1

Gender*
Is it a newborn?*
Products have been taken :
Trimester of pregnancy

Products

Step 2

Has any product (s) been interrupted ?*
Disappearance of the reaction after stopping one or more products ?*
Have any of the products been reintroduced ?*
Reappearance of the reaction after reintroduction of one or more products ?*

Practitioner declaring

Step 3

Quality*

Doctor prescriber

Step 4

Is he a declaring doctor?*

Effect

Step 5

Severity

Step 6

How serious ?*

Evolution

Step 7

What is the evolution?*