ID
Hidden
CA1
*
Hidden
CA2
*
Hidden
CA3
*
Hidden
CA4
*
Hidden
SE
*
Please click next to continue.
Use of the physiological solution: you have applied it to yourself.
Why have you
recently
benefited from the physiological solution? (Multiple answers possible)
Sans titre
*
Nose cleaning
Eye cleaning
Ear cleaning
Cleaning a wound
Inhalation (aerosol therapy)
Hidden
CAS1_Q1A
Use of the physiological solution: you have applied it to yourself.
You have recently benefited from the physiological solution
for nose cleaning.
Specify : (more than one answer possible)
Sans titre
*
Daily nose hygiene
Stuffy nose
Runny nose
Dry nose
Frequent sneezing
Other
Specify:
*
Warning The next questions you will answer relate to the following use and indication:
Use of the physiological solution: you have applied it to yourself.
Indication : Nose cleaning / Daily nose hygiene.
Hidden
CAS1_Q1A_Q2A
Use of the physiological solution: you have applied it to yourself.
Indication: Nose cleaning / Daily nose hygiene.
When was the last time you benefited from the physiological solution
in this indication
?
Sans titre
*
Less than 1 month
1 month
2 months
3 months
4 months
5 months
6 months
More than 6 months
Be careful, your answer is not consistent with the recent use of the physiological solution indicated above. Correct your answer if necessary.
Were you pregnant or breastfeeding when you received the physiological solution?
*
No
Yes
Use of the physiological solution: you have applied it to yourself.
Indication: Nose cleaning / Daily nose hygiene.
Overall, how would you rate the efficacy of the physiological solution for cleaning the nose
Sans titre
*
0 – Not at all effective
1
2
3
4
5
6
7
8
9
10 – Highly effective
Use of the physiological solution: you have applied it to yourself.
Indication: Nose cleaning / Daily nose hygiene.
Overall, after benefiting from the physiological solution did you have the impression to have a clear nose?
Sans titre
*
0 – Strongly disagree
1
2
3
4
5
6
7
8
9
10 – Strongly agree
Use of the physiological solution: you have applied it to yourself.
Indication: Nose cleaning / Daily nose hygiene.
Overall, has the use of the physiological solution contributed to improving your daily life / quality of life?
*
0 – No change
1
2
3
4
5
6
7
8
9
10 – Much improved
Use of the physiological solution: you have applied it to yourself.
Indication: Nose cleaning / Daily nose hygiene.
On average,
when you have benefited from the physiological solution in this indication
… …What was the frequency?
Sans titre
*
Several times a day
1 time a day
Several times a week
1 time a week
Several times a month
1 time per month
Specify the average number of applications per day:
*
… For how long?
Sans titre
*
Less than a week
Between 1 week and 2 weeks
Between 2 weeks and 1 month
Between 1 and 2 months
More than 2 months
Use of the physiological solution: you have applied it to yourself.
Indication: Nose cleaning / Daily nose hygiene.
Did you experience any difficulties with the dose tip (hurtful or pain-inducing tip) when you benefited from the physiological solution?
*
No
Yes
We encourage you to contact our vigilance department at the e-mail address
materiovigilance@unither-pharma.com
to inform us of any difficulties encountered with the mouthpiece of the dose.
Use of the physiological solution: you have applied it to yourself.
Indication: Nose cleaning / Daily nose hygiene.
Did you tolerate the physiological solution well?
*
0 – Not tolerated at all
1
2
3
4
5
6
7
8
9
10 – Very well tolerated
We encourage you to contact our vigilance service at the e-mail address
materiovigilance@unither-pharma.com
to tell us why the physiological solution would not have been well tolerated.
Warning The next questions you will answer concern the following use and indication:
Use of the physiological solution: you have applied it to yourself.
Indication: Nose cleaning / Stuffy nose.
Hidden
CAS1_Q1A_Q2B
Use of the physiological solution: you have applied it to yourself.
Indication: Nose cleaning / Stuffy nose.
When was the last time you benefited from the physiological solution
in this indication
?
Sans titre
*
Less than 1 month
1 month
2 months
3 months
4 months
5 months
6 months
More than 6 months
Be careful, your answer is not consistent with the recent use of the physiological solution indicated above. Correct your answer if necessary.
Were you pregnant or breastfeeding when you received the physiological solution?
*
No
Yes
Use of the physiological solution: you have applied it to yourself.
Indication: Nose cleaning / Stuffy nose.
Overall, how would you rate the efficacy of the physiological solution for decongesting the nose?
Sans titre
*
0 – Not at all effective
1
2
3
4
5
6
7
8
9
10 – Highly effective
Use of the physiological solution: you have applied it to yourself.
Indication: Nose cleaning / Stuffy nose.
Overall, after benefiting from the physiological solution did you have the impression to breathe easier?
Sans titre
*
0 – Strongly disagree
1
2
3
4
5
6
7
8
9
10 – Strongly agree
Use of the physiological solution: you have applied it to yourself.
Indication: Nose cleaning / Stuffy nose.
Overall, has the use of the physiological solution contributed to improving your daily life / quality of life?
*
0 – No change
1
2
3
4
5
6
7
8
9
10 – Much improved
Use of the physiological solution: you have applied it to yourself.
Indication: Nose cleaning / Stuffy nose.
On average,
when you have benefited from the physiological solution in this indication
… …what was the frequency?
Sans titre
*
Several times a day
1 time a day
Several times a week
1 time a week
Several times a month
1 time per month
Specify the average number of applications per day:
*
…for how long?
Sans titre
*
Less than a week
Between 1 week and 2 weeks
Between 2 weeks and 1 month
Between 1 and 2 months
More than 2 months
Use of the physiological solution: you have applied it to yourself.
Indication: Nose cleaning / Stuffy nose.
Did you experience any difficulties with the dose tip (hurtful or pain-inducing tip) when you benefited from the physiological solution?
*
No
Yes
We encourage you to contact our vigilance department at the e-mail address
materiovigilance@unither-pharma.com
to inform us of any difficulties encountered with the mouthpiece of the dose.
Use of the physiological solution: you have applied it to yourself.
Indication: Nose cleaning / Stuffy nose.
Did you tolerate the physiological solution well?
*
0 – Not tolerated at all
1
2
3
4
5
6
7
8
9
10 – Very well tolerated
We encourage you to contact our vigilance service at the e-mail address
materiovigilance@unither-pharma.com
to tell us why the physiological solution would not have been well tolerated.
Warning The next questions you will answer concern the following use and indication:
Use of the physiological solution: you have applied it to yourself.
Indication: Nose cleaning / Runny nose.
Hidden
CAS1_Q1A_Q2C
Use of the physiological solution: you have applied it to yourself.
Indication: Nose cleaning / Runny nose.
When was the last time you benefited from the physiological solution
in this indication
?
Sans titre
*
Less than 1 month
1 month
2 months
3 months
4 months
5 months
6 months
More than 6 months
Be careful, your answer is not consistent with the recent use of the physiological solution indicated above. Correct your answer if necessary.
Were you pregnant or breastfeeding when you received the physiological solution?
*
No
Yes
Use of the physiological solution: you have applied it to yourself.
Indication: Nose cleaning / Runny nose.
Overall, how would you rate the efficacy of the physiological solution for decreasing nasal discharge?
Sans titre
*
0 – Not at all effective
1
2
3
4
5
6
7
8
9
10 – Highly effective
Use of the physiological solution: you have applied it to yourself.
Indication: Nose cleaning / Runny nose.
Overall, after benefiting from the physiological solution did you have the impression to be less irritated in the nose?
Sans titre
*
0 – Strongly disagree
1
2
3
4
5
6
7
8
9
10 – Strongly agree
Use of the physiological solution: you have applied it to yourself.
Indication: Nose cleaning / Runny nose.
Overall, has the use of the physiological solution contributed to improving your daily life / quality of life?
*
0 – No change
1
2
3
4
5
6
7
8
9
10 – Much improved
Use of the physiological solution: you have applied it to yourself.
Indication: Nose cleaning / Runny nose.
On average,
when you have benefited from the physiological solution in this indication
… …what was the frequency?
Sans titre
*
Several times a day
1 time a day
Several times a week
1 time a week
Several times a month
1 time per month
Specify the average number of applications per day:
*
…for how long?
Sans titre
*
Less than a week
Between 1 week and 2 weeks
Between 2 weeks and 1 month
Between 1 and 2 months
More than 2 months
Use of the physiological solution: you have applied it to yourself.
Indication: Nose cleaning / Runny nose.
Did you experience any difficulties with the dose tip (hurtful or pain-inducing tip) when you benefited from the physiological solution?
*
No
Yes
We encourage you to contact our vigilance department at the e-mail address
materiovigilance@unither-pharma.com
to inform us of any difficulties encountered with the mouthpiece of the dose.
Use of the physiological solution: you have applied it to yourself.
Indication: Nose cleaning / Runny nose.
Did you tolerate the physiological solution well?
*
0 – Not tolerated at all
1
2
3
4
5
6
7
8
9
10 – Very well tolerated
We encourage you to contact our vigilance service at the e-mail address
materiovigilance@unither-pharma.com
to tell us why the physiological solution would not have been well tolerated.
Warning The next questions you will answer concern the following use and indication:
Use of the physiological solution: you have applied it to yourself.
Indication: Nose cleaning / Dry nose.
Hidden
CAS1_Q1A_Q2D
Use of the physiological solution: you have applied it to yourself.
Indication: Nose cleaning / Dry nose.
When was the last time you benefited from the physiological solution
in this indication
?
Sans titre
*
Less than 1 month
1 month
2 months
3 months
4 months
5 months
6 months
More than 6 months
Be careful, your answer is not consistent with the recent use of the physiological solution indicated above. Correct your answer if necessary.
Were you pregnant or breastfeeding when you received the physiological solution?
*
No
Yes
Use of the physiological solution: you have applied it to yourself.
Indication: Nose cleaning / Dry nose.
Overall, how would you rate the efficacy of the physiological solution for moistening the nose?
Sans titre
*
0 – Not at all effective
1
2
3
4
5
6
7
8
9
10 – Highly effective
Use of the physiological solution: you have applied it to yourself.
Indication: Nose cleaning / Dry nose.
Overall, after benefiting from the physiological solution did you have the impression to have a healthier nasal mucosa?
Sans titre
*
0 – Strongly disagree
1
2
3
4
5
6
7
8
9
10 – Strongly agree
Use of the physiological solution: you have applied it to yourself.
Indication: Nose cleaning / Dry nose.
Overall, has the use of the physiological solution contributed to improving your daily life / quality of life?
*
0 – No change
1
2
3
4
5
6
7
8
9
10 – Much improved
Use of the physiological solution: you have applied it to yourself.
Indication: Nose cleaning / Dry nose.
On average,
when you have benefited from the physiological solution in this indication
… …what was the frequency?
Sans titre
*
Several times a day
1 time a day
Several times a week
1 time a week
Several times a month
1 time per month
Specify the average number of applications per day:
*
…for how long?
Sans titre
*
Less than a week
Between 1 week and 2 weeks
Between 2 weeks and 1 month
Between 1 and 2 months
More than 2 months
Use of the physiological solution: you have applied it to yourself.
Indication: Nose cleaning / Dry nose.
Did you experience any difficulties with the dose tip (hurtful or pain-inducing tip) when you benefited from the physiological solution?
*
No
Yes
We encourage you to contact our vigilance department at the e-mail address
materiovigilance@unither-pharma.com
to inform us of any difficulties encountered with the mouthpiece of the dose.
Use of the physiological solution: you have applied it to yourself.
Indication: Nose cleaning / Dry nose.
Did you tolerate the physiological solution well?
*
0 – Not tolerated at all
1
2
3
4
5
6
7
8
9
10 – Very well tolerated
We encourage you to contact our vigilance service at the e-mail address
materiovigilance@unither-pharma.com
to tell us why the physiological solution would not have been well tolerated.
Warning The next questions you will answer concern the following use and indication:
Use of the physiological solution: you have applied it to yourself.
Indication: Nose cleaning / Frequent sneezing.
Hidden
CAS1_Q1A_Q2E
Use of the physiological solution: you have applied it to yourself.
Indication: Nose cleaning / Frequent sneezing.
When was the last time you benefited from the physiological solution
in this indication
?
Sans titre
*
Less than 1 month
1 month
2 months
3 months
4 months
5 months
6 months
More than 6 months
Be careful, your answer is not consistent with the recent use of the physiological solution indicated above. Correct your answer if necessary.
Were you pregnant or breastfeeding when you received the physiological solution?
*
No
Yes
Use of the physiological solution: you have applied it to yourself.
Indication: Nose cleaning / Frequent sneezing.
Overall, how would you rate the efficacy of the physiological solution for decreasing the frequency of sneezing?
Sans titre
*
0 – Not at all effective
1
2
3
4
5
6
7
8
9
10 – Highly effective
Use of the physiological solution: you have applied it to yourself.
Indication: Nose cleaning / Frequent sneezing.
Overall, after benefiting from the physiological solution did you have the impression to have reduced nose itching?
Sans titre
*
0 – Strongly disagree
1
2
3
4
5
6
7
8
9
10 – Strongly agree
Use of the physiological solution: you have applied it to yourself.
Indication: Nose cleaning / Frequent sneezing.
Overall, has the use of the physiological solution contributed to improving your daily life / quality of life?
*
0 – No change
1
2
3
4
5
6
7
8
9
10 – Much improved
Use of the physiological solution: you have applied it to yourself.
Indication: Nose cleaning / Frequent sneezing.
On average,
when you have benefited from the physiological solution in this indication
… …what was the frequency?
Sans titre
*
Several times a day
1 time a day
Several times a week
1 time a week
Several times a month
1 time per month
Specify the average number of applications per day:
*
…for how long?
Sans titre
*
Less than a week
Between 1 week and 2 weeks
Between 2 weeks and 1 month
Between 1 and 2 months
More than 2 months
Use of the physiological solution: you have applied it to yourself.
Indication: Nose cleaning / Frequent sneezing.
Did you experience any difficulties with the dose tip (hurtful or pain-inducing tip) when you benefited from the physiological solution?
*
No
Yes
We encourage you to contact our vigilance department at the e-mail address
materiovigilance@unither-pharma.com
to inform us of any difficulties encountered with the mouthpiece of the dose.
Use of the physiological solution: you have applied it to yourself.
Indication: Nose cleaning / Frequent sneezing.
Did you tolerate the physiological solution well?
*
0 – Not tolerated at all
1
2
3
4
5
6
7
8
9
10 – Very well tolerated
We encourage you to contact our vigilance service at the e-mail address
materiovigilance@unither-pharma.com
to tell us why the physiological solution would not have been well tolerated.
Warning The next questions you will answer concern the following use and indication:
Use of the physiological solution: you have applied it to yourself.
Indication: Nose cleaning / Other.
Hidden
CAS1_Q1A_Q2F
Use of the physiological solution: you have applied it to yourself.
Indication: Nose cleaning / Other.
When was the last time you benefited from the physiological solution
in this indication
?
Sans titre
*
Less than 1 month
1 month
2 months
3 months
4 months
5 months
6 months
More than 6 months
Be careful, your answer is not consistent with the recent use of the physiological solution indicated above. Correct your answer if necessary.
Were you pregnant or breastfeeding when you received the physiological solution?
*
No
Yes
Use of the physiological solution: you have applied it to yourself.
Indication: Nose cleaning / Other.
Overall, has the use of the physiological solution contributed to improving your daily life / quality of life?
*
0 – No change
1
2
3
4
5
6
7
8
9
10 – Much improved
Use of the physiological solution: you have applied it to yourself.
Indication: Nose cleaning / Other.
On average,
when you have benefited from the physiological solution in this indication
… …what was the frequency?
Sans titre
*
Several times a day
1 time a day
Several times a week
1 time a week
Several times a month
1 time per month
Specify the average number of applications per day:
*
…for how long?
Sans titre
*
Less than a week
Between 1 week and 2 weeks
Between 2 weeks and 1 month
Between 1 and 2 months
More than 2 months
Use of the physiological solution: you have applied it to yourself.
Indication: Nose cleaning / Other.
Did you experience any difficulties with the dose tip (hurtful or pain-inducing tip) when you benefited from the physiological solution?
*
No
Yes
We encourage you to contact our vigilance department at the e-mail address
materiovigilance@unither-pharma.com
to inform us of any difficulties encountered with the mouthpiece of the dose.
Use of the physiological solution: you have applied it to yourself.
Indication: Nose cleaning / Other.
Did you tolerate the physiological solution well?
*
0 – Not tolerated at all
1
2
3
4
5
6
7
8
9
10 – Very well tolerated
We encourage you to contact our vigilance service at the e-mail address
materiovigilance@unither-pharma.com
to tell us why the physiological solution would not have been well tolerated.
Hidden
CAS1_Q1B
Use of the physiological solution: you have applied it to yourself.
You recently benefited from the physiological solution
for eye cleaning.
Specify: (more than one answer possible)
Sans titre
*
Daily eye hygiene
Removal of contaminant/foreign body
Conjunctivitis
Other
Specify:
*
Warning The next questions you will answer concern the following use and indication:
Use of the physiological solution: you have applied it to yourself.
Indication: Eye cleaning / Daily eye hygiene.
Hidden
CAS1_Q1B_Q2A
Use of the physiological solution: you have applied it to yourself.
Indication: Eye cleaning / Daily eye hygiene.
When was the last time you benefited from the physiological solution
in this indication
?
Sans titre
*
Less than 1 month
1 month
2 months
3 months
4 months
5 months
6 months
More than 6 months
Be careful, your answer is not consistent with the recent use of the physiological solution indicated above. Correct your answer if necessary.
Were you pregnant or breastfeeding when you received the physiological solution?
*
No
Yes
Use of the physiological solution: you have applied it to yourself.
Indication: Eye cleaning / Daily eye hygiene.
Do you wear contact lenses?
*
No
Yes
Use of the physiological solution: you have applied it to yourself.
Indication: Eye cleaning / Daily eye hygiene.
Overall, how would you rate the efficacy of the physiological solution for cleansing the eyes?
Sans titre
*
0 – Not at all effective
1
2
3
4
5
6
7
8
9
10 – Highly effective
Use of the physiological solution: you have applied it to yourself.
Indication: Eye cleaning / Daily eye hygiene.
Overall, after benefiting from the physiological solution did you have the impression less irritated eyes?
Sans titre
*
0 – Strongly disagree
1
2
3
4
5
6
7
8
9
10 – Strongly agree
Use of the physiological solution: you have applied it to yourself.
Indication: Eye cleaning / Daily eye hygiene.
Overall, has the use of the physiological solution contributed to improving your daily life / quality of life?
*
0 – No change
1
2
3
4
5
6
7
8
9
10 – Much improved
Use of the physiological solution: you have applied it to yourself.
Indication: Eye cleaning / Daily eye hygiene.
On average,
when you have benefited from the physiological solution in this indication
… …what was the frequency?
Sans titre
*
Several times a day
1 time a day
Several times a week
1 time a week
Several times a month
1 time per month
Specify the average number of applications per day:
*
…for how long?
Sans titre
*
Less than a week
Between 1 week and 2 weeks
Between 2 weeks and 1 month
Between 1 and 2 months
More than 2 months
Use of the physiological solution: you have applied it to yourself.
Indication: Eye cleaning / Daily eye hygiene.
Did you experience any difficulties with the dose tip (hurtful or pain-inducing tip) when you benefited from the physiological solution?
*
No
Yes
We encourage you to contact our vigilance department at the e-mail address
materiovigilance@unither-pharma.com
to inform us of any difficulties encountered with the mouthpiece of the dose.
Use of the physiological solution: you have applied it to yourself.
Indication: Eye cleaning / Daily eye hygiene.
Did you tolerate the physiological solution well?
*
0 – Not tolerated at all
1
2
3
4
5
6
7
8
9
10 – Very well tolerated
We encourage you to contact our vigilance service at the e-mail address
materiovigilance@unither-pharma.com
to tell us why the physiological solution would not have been well tolerated.
Warning The next questions you will answer concern the following use and indication:
Use of the physiological solution: you have applied it to yourself.
Indication: Eye cleaning / Removal of contaminant/foreign body
Hidden
CAS1_Q1B_Q2B
Use of the physiological solution: you have applied it to yourself.
Indication: Eye cleaning / Removal of contaminant/foreign body.
When was the last time you benefited from the physiological solution
in this indication
?
Sans titre
*
Less than 1 month
1 month
2 months
3 months
4 months
5 months
6 months
More than 6 months
Be careful, your answer is not consistent with the recent use of the physiological solution indicated above. Correct your answer if necessary.
Were you pregnant or breastfeeding when you received the physiological solution?
*
No
Yes
Use of the physiological solution: you have applied it to yourself.
Indication: Eye cleaning / Removal of contaminant/foreign body.
Do you wear contact lenses?
*
No
Yes
Use of the physiological solution: you have applied it to yourself.
Indication: Eye cleaning / Removal of contaminant/foreign body.
Has the contaminant been removed?
*
Yes, totally
Yes partially
No
How many doses of physiological solution were used?
*
Use of the physiological solution: you have applied it to yourself.
Indication: Eye cleaning / Removal of contaminant/foreign body.
Overall, how would you rate the efficacy of the physiological solution for removing contaminant/foreign body?
Sans titre
*
0 – Not at all effective
1
2
3
4
5
6
7
8
9
10 – Highly effective
Use of the physiological solution: you have applied it to yourself.
Indication: Eye cleaning / Removal of contaminant/foreign body.
Overall, after benefiting from the physiological solution did you have the impression less irritated eyes?
Sans titre
*
0 – Strongly disagree
1
2
3
4
5
6
7
8
9
10 – Strongly agree
Use of the physiological solution: you have applied it to yourself.
Indication: Eye cleaning / Removal of contaminant/foreign body.
Overall, has the use of the physiological solution contributed to improving your daily life / quality of life?
*
0 – No change
1
2
3
4
5
6
7
8
9
10 – Much improved
Use of the physiological solution: you have applied it to yourself.
Indication: Eye cleaning / Removal of contaminant/foreign body.
Did you experience any difficulties with the dose tip (hurtful or pain-inducing tip) when you benefited from the physiological solution?
*
No
Yes
We encourage you to contact our vigilance department at the e-mail address
materiovigilance@unither-pharma.com
to inform us of any difficulties encountered with the mouthpiece of the dose.
Use of the physiological solution: you have applied it to yourself.
Indication: Eye cleaning / Removal of contaminant/foreign body.
Did you tolerate the physiological solution well?
*
0 – Not tolerated at all
1
2
3
4
5
6
7
8
9
10 – Very well tolerated
We encourage you to contact our vigilance service at the e-mail address
materiovigilance@unither-pharma.com
to tell us why the physiological solution would not have been well tolerated.
Warning The next questions you will answer concern the following use and indication:
Use of the physiological solution: you have applied it to yourself.
Indication: Eye cleaning / Conjunctivitis.
Hidden
CAS1_Q1B_Q2BBIS
Use of the physiological solution: you have applied it to yourself.
Indication: Eye cleaning / Conjunctivitis.
When was the last time you benefited from the physiological solution
in this indication
?
Sans titre
*
Less than 1 month
1 month
2 months
3 months
4 months
5 months
6 months
More than 6 months
Be careful, your answer is not consistent with the recent use of the physiological solution indicated above. Correct your answer if necessary.
Were you pregnant or breastfeeding when you received the physiological solution?
*
No
Yes
Use of the physiological solution: you have applied it to yourself.
Indication: Eye cleaning / Conjunctivitis.
Do you wear contact lenses?
*
No
Yes
Use of the physiological solution: you have applied it to yourself.
Indication: Eye cleaning / Conjunctivitis.
Overall, how would you rate the efficacy of the physiological solution for cleaning, remove drips?
Sans titre
*
0 – Not at all effective
1
2
3
4
5
6
7
8
9
10 – Highly effective
Use of the physiological solution: you have applied it to yourself.
Indication: Eye cleaning / Conjunctivitis.
Overall, after benefiting from the physiological solution did you have the impression to have a decrease in symptoms related to conjunctivitis (red eyes, discharge, pain, irritation, …)?
Sans titre
*
0 – Strongly disagree
1
2
3
4
5
6
7
8
9
10 – Strongly agree
Use of the physiological solution: you have applied it to yourself.
Indication: Eye cleaning / Conjunctivitis.
Overall, has the use of the physiological solution contributed to improving your daily life / quality of life?
*
0 – No change
1
2
3
4
5
6
7
8
9
10 – Much improved
Use of the physiological solution: you have applied it to yourself.
Indication: Eye cleaning / Conjunctivitis.
On average,
when you have benefited from the physiological solution in this indication
… …what was the frequency?
Sans titre
*
Several times a day
1 time a day
Several times a week
1 time a week
Several times a month
1 time per month
Specify the average number of applications per day:
*
…for how long?
Sans titre
*
Less than a week
Between 1 week and 2 weeks
Between 2 weeks and 1 month
Between 1 and 2 months
More than 2 months
Use of the physiological solution: you have applied it to yourself.
Indication: Eye cleaning / Conjunctivitis.
Did you experience any difficulties with the dose tip (hurtful or pain-inducing tip) when you benefited from the physiological solution?
*
No
Yes
We encourage you to contact our vigilance department at the e-mail address
materiovigilance@unither-pharma.com
to inform us of any difficulties encountered with the mouthpiece of the dose.
Use of the physiological solution: you have applied it to yourself.
Indication: Eye cleaning / Conjunctivitis.
Did you tolerate the physiological solution well?
*
0 – Not tolerated at all
1
2
3
4
5
6
7
8
9
10 – Very well tolerated
We encourage you to contact our vigilance service at the e-mail address
materiovigilance@unither-pharma.com
o tell us why the physiological solution would not have been well tolerated.
Warning The next questions you will answer concern the following use and indication:
Use of the physiological solution: you have applied it to yourself.
Indication: Eye cleaning / Other.
Hidden
CAS1_Q1B_Q2C
Use of the physiological solution: you have applied it to yourself.
/br>
Indication: Eye cleaning / Other.
When was the last time you benefited from the physiological solution
in this indication
?
Sans titre
*
Less than 1 month
1 month
2 months
3 months
4 months
5 months
6 months
More than 6 months
Be careful, your answer is not consistent with the recent use of the physiological solution indicated above. Correct your answer if necessary.
Were you pregnant or breastfeeding when you received the physiological solution?
*
No
Yes
Use of the physiological solution: you have applied it to yourself.
Indication: Eye cleaning / Other.
Do you wear contact lenses?
*
No
Yes
Use of the physiological solution: you have applied it to yourself.
Indication: Eye cleaning / Other.
Overall, has the use of the physiological solution contributed to improving your daily life / quality of life?
*
0 – No change
1
2
3
4
5
6
7
8
9
10 – Much improved
Use of the physiological solution: you have applied it to yourself.
Indication: Eye cleaning / Other.
On average,
when you have benefited from the physiological solution in this indication
… …what was the frequency?
Sans titre
*
Several times a day
1 time a day
Several times a week
1 time a week
Several times a month
1 time a month
Specify the average number of applications per day:
*
…for how long?
Sans titre
*
Less than a week
Between 1 week and 2 weeks
Between 2 weeks and 1 month
Between 1 and 2 months
More than 2 months
Use of the physiological solution: you have applied it to yourself.
Indication: Eye cleaning / Other.
Did you experience any difficulties with the dose tip (hurtful or pain-inducing tip) when you benefited from the physiological solution?
*
No
Yes
We encourage you to contact our vigilance department at the e-mail address
materiovigilance@unither-pharma.com
to inform us of any difficulties encountered with the mouthpiece of the dose.
Use of the physiological solution: you have applied it to yourself.
Indication: Eye cleaning / Other.
Did you tolerate the physiological solution well?
*
0 – Not tolerated at all
1
2
3
4
5
6
7
8
9
10 – Very well tolerated
We encourage you to contact our vigilance service at the e-mail address
materiovigilance@unither-pharma.com
to tell us why the physiological solution would not have been well tolerated.
Hidden
CAS1_Q1C
Use of the physiological solution: you have applied it to yourself.
You have recently benefited from the physiological solution
for ear cleaning
Specify: (more than one answer possible)
Sans titre
*
Daily Ear Hygiene
Removal of excess earwax or foreign bodies
Other
Specify:
*
Warning The next questions you will answer concern the following use and indication:
Use of the physiological solution: you have applied it to yourself.
Indication: Ear cleaning / Daily Ear Hygiene.
Hidden
CAS1_Q1C_Q2A
Use of the physiological solution: you have applied it to yourself.
Indication: Ear cleaning / Daily Ear Hygiene.
When was the last time you benefited from the physiological solution
in this indication
?
Sans titre
*
Less than 1 month
1 month
2 months
3 months
4 months
5 months
6 months
More than 6 months
Be careful, your answer is not consistent with the recent use of the physiological solution indicated above. Correct your answer if necessary.
Were you pregnant or breastfeeding when you received the physiological solution?
*
No
Yes
Use of the physiological solution: you have applied it to yourself.
Indication: Ear cleaning / Daily Ear Hygiene.
Overall, how would you rate the efficacy of the physiological solution for cleaning the ears?
Sans titre
*
0 – Not at all effective
1
2
3
4
5
6
7
8
9
10 – Highly effective
Use of the physiological solution: you have applied it to yourself.
Indication: Ear cleaning / Daily Ear Hygiene.
Overall, after benefiting from the physiological solution did you have the impression to have less congested ears?
Sans titre
*
0 – Strongly disagree
1
2
3
4
5
6
7
8
9
10 – Strongly agree
Use of the physiological solution: you have applied it to yourself.
Indication: Ear cleaning / Daily Ear Hygiene.
Overall, has the use of the physiological solution contributed to improving your daily life / quality of life?
*
0 – No change
1
2
3
4
5
6
7
8
9
10 – Much improved
Use of the physiological solution: you have applied it to yourself.
Indication: Ear cleaning / Daily Ear Hygiene.
On average,
when you have benefited from the physiological solution in this indication
… …what was the frequency?
Sans titre
*
Several times a day
1 time a day
Several times a week
1 time a week
Several times a month
1 time a month
Specify the average number of applications per day:
*
…for how long?
Sans titre
*
Less than a week
Between 1 week and 2 weeks
Between 2 weeks and 1 month
Between 1 and 2 months
More than 2 month
Use of the physiological solution: you have applied it to yourself.
Indication: Ear cleaning / Daily Ear Hygiene.
Did you experience any difficulties with the dose tip (hurtful or pain-inducing tip) when you benefited from the physiological solution?
*
No
Yes
We encourage you to contact our vigilance department at the e-mail address
materiovigilance@unither-pharma.com
o inform us of any difficulties encountered with the mouthpiece of the dose.
Use of the physiological solution: you have applied it to yourself.
Indication: Ear cleaning / Daily Ear Hygiene.
Did you tolerate the physiological solution well?
*
0 – Not tolerated at all
1
2
3
4
5
6
7
8
9
10 – Very well tolerated
We encourage you to contact our vigilance service at the e-mail address
materiovigilance@unither-pharma.com
to tell us why the physiological solution would not have been well tolerated.
Warning The next questions you will answer concern the following use and indication:
Use of the physiological solution: you have applied it to yourself.
Indication: Ear cleaning / Removal of excess earwax or foreign bodies.
Hidden
CAS1_Q1C_Q2B
Use of the physiological solution: you have applied it to yourself.
Indication: Ear cleaning / Removal of excess earwax or foreign bodies.
When was the last time you benefited from the physiological solution
in this indication
?
Sans titre
*
Less than 1 month
1 month
2 months
3 months
4 months
5 months
6 months
More than 6 months
Be careful, your answer is not consistent with the recent use of the physiological solution indicated above. Correct your answer if necessary.
Were you pregnant or breastfeeding when you received the physiological solution?
*
No
Yes
Use of the physiological solution: you have applied it to yourself.
Indication: Ear cleaning / Removal of excess earwax or foreign bodies.
Has excess earwax or foreign body been removed?
*
Yes, totally
Yes, partially
No
How many doses of physiological solution were used?
*
Use of the physiological solution: you have applied it to yourself.
Indication: Ear cleaning / Removal of excess earwax or foreign bodies.
Overall, how would you rate the efficacy of the physiological solution for removing excess earwax or the body stranger?
Sans titre
*
0 – Not at all effective
1
2
3
4
5
6
7
8
9
10 – Highly effective
Use of the physiological solution: you have applied it to yourself.
Indication: Ear cleaning / Removal of excess earwax or foreign bodies.
Overall, after benefiting from the physiological solution did you have the impression to have an improved hearing?
Sans titre
*
0 – Strongly disagree
1
2
3
4
5
6
7
8
9
10 – Strongly agree
Use of the physiological solution: you have applied it to yourself.
Indication: Ear cleaning / Removal of excess earwax or foreign bodies.
Overall, has the use of the physiological solution contributed to improving your daily life / quality of life?
*
0 – No change
1
2
3
4
5
6
7
8
9
10 – Much improved
Use of the physiological solution: you have applied it to yourself.
Indication: Ear cleaning / Removal of excess earwax or foreign bodies.
Did you experience any difficulties with the dose tip (hurtful or pain-inducing tip) when you benefited from the physiological solution?
*
No
Yes
We encourage you to contact our vigilance department at the e-mail address
materiovigilance@unither-pharma.com
to inform us of any difficulties encountered with the mouthpiece of the dose.
Use of the physiological solution: you have applied it to yourself.
Indication: Ear cleaning / Removal of excess earwax or foreign bodies.
Did you tolerate the physiological solution well?
*
0 – Not tolerated at all
1
2
3
4
5
6
7
8
9
10 – Very well tolerated
We encourage you to contact our vigilance service at the e-mail address
materiovigilance@unither-pharma.com
to tell us why the physiological solution would not have been well tolerated.
Warning The next questions you will answer concern the following use and indication:
Use of the physiological solution: you have applied it to yourself.
Indication: Ear cleaning / Other.
Hidden
CAS1_Q1C_Q2C
Use of the physiological solution: you have applied it to yourself.
Indication: Ear cleaning / Other.
When was the last time you benefited from the physiological solution
in this indication
?
Sans titre
*
Less than 1 month
1 month
2 months
3 months
4 months
5 months
6 months
More than 6 months
Be careful, your answer is not consistent with the recent use of the physiological solution indicated above. Correct your answer if necessary.
Were you pregnant or breastfeeding when you received the physiological solution?
*
No
Yes
Use of the physiological solution: you have applied it to yourself.
Indication: Ear cleaning / Other.
Overall, has the use of the physiological solution contributed to improving your daily life / quality of life?
*
0 – No change
1
2
3
4
5
6
7
8
9
10 – Much improved
Use of the physiological solution: you have applied it to yourself.
Indication: Ear cleaning / Other.
On average,
when you have benefited from the physiological solution in this indication
… …what was the frequency?
Sans titre
*
Several times a day
1 time a day
Several times a week
1 time a week
Several times a month
1 time a month
Specify the average number of applications per day:
*
…for how long?
Sans titre
*
Less than a week
Between 1 week and 2 weeks
Between 2 weeks and 1 month
Between 1 and 2 months
More than 2 months
Use of the physiological solution: you have applied it to yourself.
Indication: Ear cleaning / Other.
Did you experience any difficulties with the dose tip (hurtful or pain-inducing tip) when you benefited from the physiological solution?
*
No
Yes
We encourage you to contact our vigilance department at the e-mail address
materiovigilance@unither-pharma.com
to inform us of any difficulties encountered with the mouthpiece of the dose.
Use of the physiological solution: you have applied it to yourself.
Indication: Ear cleaning / Other.
Did you tolerate the physiological solution well?
*
0 – Not tolerated at all
1
2
3
4
5
6
7
8
9
10 – Very well tolerated
We encourage you to contact our vigilance service at the e-mail address
materiovigilance@unither-pharma.com
to tell us why the physiological solution would not have been well tolerated.
Hidden
CAS1_Q1D
Use of the physiological solution: you have applied it to yourself.
You have recently benefited from the physiological solution
for cleaning a wound
Specify: (more than one answer possible)
Sans titre
*
Rinsing a wound without apparent contaminants
Rinsing a wound with apparent contaminants
Other
Specify:
*
Warning The next questions you will answer concern the following use and indication:
Use of the physiological solution: you have applied it to yourself.
Indication: Cleaning a wound / Rinsing a wound without apparent contaminants.
Hidden
CAS1_Q1D_Q2A
Use of the physiological solution: you have applied it to yourself.
Indication: Cleaning a wound / Rinsing a wound without apparent contaminants.
When was the last time you benefited from the physiological solution
in this indication
?
Sans titre
*
Less than 1 month
1 month
2 months
3 months
4 months
5 months
6 months
More than 6 months
Be careful, your answer is not consistent with the recent use of the physiological solution indicated above. Correct your answer if necessary.
Were you pregnant or breastfeeding when you received the physiological solution?
*
No
Yes
Use of the physiological solution: you have applied it to yourself.
Indication: Cleaning a wound / Rinsing a wound without apparent contaminants.
Overall, how would you rate the efficacy of the physiological solution for cleaning a wound?
Sans titre
*
0 – Not at all effective
1
2
3
4
5
6
7
8
9
10 – Highly effective
Use of the physiological solution: you have applied it to yourself.
Indication: Cleaning a wound / Rinsing a wound without apparent contaminants.
Overall, after benefiting from the physiological solution did you have the impression to have a healthier wound?
Sans titre
*
0 – Strongly disagree
1
2
3
4
5
6
7
8
9
10 – Strongly agree
Use of the physiological solution: you have applied it to yourself.
Indication: Cleaning a wound / Rinsing a wound without apparent contaminants.
Overall, has the use of the physiological solution contributed to improving your daily life / quality of life?
*
0 – No change
1
2
3
4
5
6
7
8
9
10 – Much improved
Use of the physiological solution: you have applied it to yourself.
Indication: Cleaning a wound / Rinsing a wound without apparent contaminants.
On average,
when you have benefited from the physiological solution in this indication
… …what was the frequency?
Sans titre
*
Several times a day
1 time a day
Several times a week
1 time a week
Several times a month
1 time a month
Specify the average number of applications per day:
*
…for how long?
Sans titre
*
Less than a week
Between 1 week and 2 weeks
Between 2 weeks and 1 month
Between 1 and 2 months
More than 2 months
Use of the physiological solution: you have applied it to yourself.
Indication: Cleaning a wound / Rinsing a wound without apparent contaminants.
Did you experience any difficulties with the dose tip (hurtful or pain-inducing tip) when you benefited from the physiological solution?
*
No
Yes
We encourage you to contact our vigilance department at the e-mail address
materiovigilance@unither-pharma.com
to inform us of any difficulties encountered with the mouthpiece of the dose.
Use of the physiological solution: you have applied it to yourself.
Indication: Cleaning a wound / Rinsing a wound without apparent contaminants.
During the period in which your wound was cleaned with the physiological solution, did the wound become infected?
*
Yes, totally
Yes, partially
No
Use of the physiological solution: you have applied it to yourself.
Indication: Cleaning a wound / Rinsing a wound without apparent contaminants.
Did you tolerate the physiological solution well?
*
0 – Not tolerated at all
1
2
3
4
5
6
7
8
9
10 – Very well tolerated
We encourage you to contact our vigilance service at the e-mail address
materiovigilance@unither-pharma.com
to tell us why the physiological solution would not have been well tolerated.
Warning The next questions you will answer concern the following use and indication:
Use of the physiological solution: you have applied it to yourself.
Indication: Cleaning a wound / Rinsing a wound with apparent contaminants.
Hidden
CAS1_Q1D_Q2B
Use of the physiological solution: you have applied it to yourself.
Indication: Cleaning a wound / Rinsing a wound with apparent contaminants.
When was the last time you benefited from the physiological solution
in this indication
?
Sans titre
*
Less than 1 month
1 month
2 months
3 months
4 months
5 months
6 months
More than 6 months
Be careful, your answer is not consistent with the recent use of the physiological solution indicated above. Correct your answer if necessary.
Were you pregnant or breastfeeding when you received the physiological solution?
*
No
Yes
Use of the physiological solution: you have applied it to yourself.
Indication: Cleaning a wound / Rinsing a wound with apparent contaminants.
Has the contaminant been removed?
*
Yes, totally
Yes partially
No
How many doses of physiological solution were used?
*
Use of the physiological solution: you have applied it to yourself.
Indication: Cleaning a wound / Rinsing a wound with apparent contaminants.
Overall, how would you rate the efficacy of the physiological solution for removing contaminants from the wound?
Sans titre
*
0 – Not at all effective
1
2
3
4
5
6
7
8
9
10 – Highly effective
Use of the physiological solution: you have applied it to yourself.
Indication: Cleaning a wound / Rinsing a wound with apparent contaminants.
Overall, after benefiting from the physiological solution did you have the impression to have a healthier wound?
Sans titre
*
0 – Strongly disagree
1
2
3
4
5
6
7
8
9
10 – Strongly agree
Use of the physiological solution: you have applied it to yourself.
Indication: Cleaning a wound / Rinsing a wound with apparent contaminants.
Overall, has the use of the physiological solution contributed to improving your daily life / quality of life?
*
0 – No change
1
2
3
4
5
6
7
8
9
10 – Much improved
Use of the physiological solution: you have applied it to yourself.
Indication: Cleaning a wound / Rinsing a wound with apparent contaminants.
Did you experience any difficulties with the dose tip (hurtful or pain-inducing tip) when you benefited from the physiological solution?
*
No
Yes
We encourage you to contact our vigilance department at the e-mail address
materiovigilance@unither-pharma.com
to inform us of any difficulties encountered with the mouthpiece of the dose.
Use of the physiological solution: you have applied it to yourself.
Indication: Cleaning a wound / Rinsing a wound with apparent contaminants.
Did you tolerate the physiological solution well?
*
0 – Not tolerated at all
1
2
3
4
5
6
7
8
9
10 – Very well tolerated
We encourage you to contact our vigilance service at the e-mail address
materiovigilance@unither-pharma.com
to tell us why the physiological solution would not have been well tolerated.
Warning The next questions you will answer concern the following use and indication:
Use of the physiological solution: you have applied it to yourself.
Indication: Cleaning a wound / Other.
Hidden
CAS1_Q1D_Q2C
Use of the physiological solution: you have applied it to yourself.
Indication: Cleaning a wound / Other.
When was the last time you benefited from the physiological solution
in this indication
?
Sans titre
*
Less than 1 month
1 month
2 months
3 months
4 months
5 months
6 months
More than 6 months
Be careful, your answer is not consistent with the recent use of the physiological solution indicated above. Correct your answer if necessary.
Were you pregnant or breastfeeding when you received the physiological solution?
*
No
Yes
Use of the physiological solution: you have applied it to yourself.
Indication: Cleaning a wound / Other.
Overall, has the use of the physiological solution contributed to improving your daily life / quality of life?
*
0 – No change
1
2
3
4
5
6
7
8
9
10 – Much improved
Use of the physiological solution: you have applied it to yourself.
Indication: Cleaning a wound / Other.
On average,
when you have benefited from the physiological solution in this indication
… …what was the frequency?
Sans titre
*
Several times a day
1 time a day
Several times a week
1 time a week
Several times a month
1 time a month
Specify the average number of applications per day:
*
…for how long?
Sans titre
*
Less than a week
Between 1 week and 2 weeks
Between 2 weeks and 1 month
Between 1 and 2 months
More than 2 months
Use of the physiological solution: you have applied it to yourself.
Indication: Cleaning a wound / Other.
Did you experience any difficulties with the dose tip (hurtful or pain-inducing tip) when you benefited from the physiological solution?
*
No
Yes
We encourage you to contact our vigilance department at the e-mail address
materiovigilance@unither-pharma.com
to inform us of any difficulties encountered with the mouthpiece of the dose.
Use of the physiological solution: you have applied it to yourself.
Indication: Cleaning a wound / Other.
Did you tolerate the physiological solution well?
*
0 – Not tolerated at all
1
2
3
4
5
6
7
8
9
10 – Very well tolerated
We encourage you to contact our vigilance service at the e-mail address
materiovigilance@unither-pharma.com
to tell us why the physiological solution would not have been well tolerated.
Hidden
CAS1_Q1E
Use of the physiological solution: you have applied it to yourself.
You have recently benefited from the physiological solution
for inhalation (aerosol therapy).
Specify: (more than one answer possible)
Sans titre
*
Humidification breathing to facilitate evacuation of bronchial secretions
Dilution of an inhalation drug
Other
Specify:
*
Warning The next questions you will answer concern the following use and indication:
Use of the physiological solution: you have applied it to yourself.
Indication: Inhalation (aerosol therapy) / Humidification breathing to facilitate evacuation of bronchial secretions.
Hidden
CAS1_Q1E_Q2A
Use of the physiological solution: you have applied it to yourself.
Indication: Inhalation (aerosol therapy) / Humidification breathing to facilitate evacuation of bronchial secretions.
When was the last time you benefited from the physiological solution
in this indication
?
Sans titre
*
Less than 1 month
1 month
2 months
3 months
4 months
5 months
6 months
More than 6 months
Be careful, your answer is not consistent with the recent use of the physiological solution indicated above. Correct your answer if Necessary.
Were you pregnant or breastfeeding when you received the physiological solution?
*
No
Yes
Use of the physiological solution: you have applied it to yourself.
Indication: Inhalation (aerosol therapy) / Humidification breathing to facilitate evacuation of bronchial secretions.
Specify the brand and model of the nebulizer used:
*
Use of the physiological solution: you have applied it to yourself.
Indication: Inhalation (aerosol therapy) / Humidification breathing to facilitate evacuation of bronchial secretions.
Overall, how would you rate the efficacy of the physiological solution for thinning bronchial secretions?
Sans titre
*
0 – Not at all effective
1
2
3
4
5
6
7
8
9
10 – Highly effective
Use of the physiological solution: you have applied it to yourself.
Indication: Inhalation (aerosol therapy) / Humidification breathing to facilitate evacuation of bronchial secretions.
Overall, after benefiting from the physiological solution did you have the impression to breathe easier?
Sans titre
*
0 – Strongly disagree
1
2
3
4
5
6
7
8
9
10 – Strongly agree
Use of the physiological solution: you have applied it to yourself.
Indication: Inhalation (aerosol therapy) / Humidification breathing to facilitate evacuation of bronchial secretions.
Overall, has the use of the physiological solution contributed to improving your daily life / quality of life?
*
0 – No change
1
2
3
4
5
6
7
8
9
10 – Much improved
Use of the physiological solution: you have applied it to yourself.
Indication: Inhalation (aerosol therapy) / Humidification breathing to facilitate evacuation of bronchial secretions.
On average,
when you have benefited from the physiological solution in this indication
… …what was the frequency?
Sans titre
*
Several times a day
1 time a day
Several times a week
1 time a week
Several times a month
1 time a month
Specify the average number of applications per day:
*
…for how long?
Sans titre
*
Less than a week
Between 1 week and 2 weeks
Between 2 weeks and 1 month
Between 1 and 2 months
More than 2 months
Use of the physiological solution: you have applied it to yourself.
Indication: Inhalation (aerosol therapy) / Humidification breathing to facilitate evacuation of bronchial secretions.
Did you tolerate the physiological solution well?
*
0 – Not tolerated at all
1
2
3
4
5
6
7
8
9
10 – Very well tolerated
We encourage you to contact our vigilance service at the e-mail address
materiovigilance@unither-pharma.com
to tell us why the physiological solution would not have been well tolerated.
Warning The next questions you will answer concern the following use and indication:
Use of the physiological solution: you have applied it to yourself.
Indication: Inhalation (aerosol therapy) / Dilution of an inhalation drug.
Hidden
CAS1_Q1E_Q2B
Use of the physiological solution: you have applied it to yourself.
Indication: Inhalation (aerosol therapy) / Dilution of an inhalation drug.
When was the last time you benefited from the physiological solution
in this indication
?
Sans titre
*
Less than 1 month
1 month
2 months
3 months
4 months
5 months
6 months
More than 6 months
Be careful, your answer is not consistent with the recent use of the physiological solution indicated above. Correct your answer if necessary.
Were you pregnant or breastfeeding when you received the physiological solution?
*
No
Yes
Use of the physiological solution: you have applied it to yourself.
Indication: Inhalation (aerosol therapy) / Dilution of an inhalation drug.
Specify the brand and model of the nebulizer used:
*
Use of the physiological solution: you have applied it to yourself.
Indication: Inhalation (aerosol therapy) / Dilution of an inhalation drug.
On average,
when you have benefited from the physiological solution in this indication
… …what was the frequency?
Sans titre
*
Several times a day
1 time a day
Several times a week
1 time a week
Several times a month
1 time a month
Specify the average number of applications per day:
*
…for how long?
Sans titre
*
Less than a week
Between 1 week and 2 weeks
Between 2 weeks and 1 month
Between 1 and 2 months
More than 2 months
Warning The next questions you will answer concern the following use and indication:
Use of the physiological solution: you have applied it to yourself.
Indication: Inhalation (aerosol therapy) / Other.
Hidden
CAS1_Q1E_Q2C
Use of the physiological solution: you have applied it to yourself.
Indication: Inhalation (aerosol therapy) / Other.
When was the last time you benefited from the physiological solution
in this indication
?
Sans titre
*
Less than 1 month
1 month
2 months
3 months
4 months
5 months
6 months
More than 6 months
Be careful, your answer is not consistent with the recent use of the physiological solution indicated above. Correct your answer if necessary.
Were you pregnant or breastfeeding when you received the physiological solution?
*
No
Yes
Use of the physiological solution: you have applied it to yourself.
Indication: Inhalation (aerosol therapy) / Other.
Specify the brand and model of the nebulizer used:
*
Use of the physiological solution: you have applied it to yourself.
Indication: Inhalation (aerosol therapy) / Other.
Overall, has the use of the physiological solution contributed to improving your daily life / quality of life?
*
0 – No change
1
2
3
4
5
6
7
8
9
10 – Much improved
Use of the physiological solution: you have applied it to yourself.
Indication: Inhalation (aerosol therapy) / Other.
On average,
when you have benefited from the physiological solution in this indication
… …what was the frequency?
Sans titre
*
Several times a day
1 time a day
Several times a week
1 time a week
Several times a month
1 time a month
Specify the average number of applications per day:
*
…for how long?
Sans titre
*
Less than a week
Between 1 week and 2 weeks
Between 2 weeks and 1 month
Between 1 and 2 months
More than 2 months
Use of the physiological solution: you have applied it to yourself.
Indication: Inhalation (aerosol therapy) / Other.
Did you tolerate the physiological solution well?
*
0 – Not tolerated at all
1
2
3
4
5
6
7
8
9
10 – Very well tolerated
We encourage you to contact our vigilance service at the e-mail address
materiovigilance@unither-pharma.com
to tell us why the physiological solution would not have been well tolerated.
