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 your child.
Why has your child
recently
benefited from the physiological solution? (Multiple answers possible)
Sans titre
*
Nose cleaning
Eye cleaning
Ear cleaning
Cleaning a wound
Inhalation (aerosol therapy)
Hidden
CAS3_Q1A
Use of the physiological solution: you have applied it to your child.
Your child have recently benefited from the physiological solution and you have applied it to your child
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 your child.
Indication : Nose cleaning / Daily nose hygiene.
Hidden
CAS3_Q1A_Q2A
Use of the physiological solution: you have applied it to your child.
Indication: Nose cleaning / Daily nose hygiene.
When was the last time your child received 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.
Use of the physiological solution: you have applied it to your child.
Indication: Nose cleaning / Daily nose hygiene.
Overall for your child, how would you rate the effectiveness 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 your child.
Indication: Nose cleaning / Daily nose hygiene.
Overall for your child, after benefiting from the physiological solution would you say that your child had 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 your child.
Indication: Nose cleaning / Daily nose hygiene.
Overall, has the use of the physiological solution contributed to improving your child's 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 your child.
Indication: Nose cleaning / Daily nose hygiene.
On average,
when your child has 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 your child.
Indication: Nose cleaning / Daily nose hygiene.
Did your child experience any difficulties with the dose tip (hurtful or pain-inducing tip) when receiving 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 your child.
Indication: Nose cleaning / Daily nose hygiene.
Has your child tolerated 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 your child.
Indication: Nose cleaning / Stuffy nose.
Hidden
CAS3_Q1A_Q2B
Use of the physiological solution: you have applied it to your child.
Indication: Nose cleaning / Stuffy nose.
When was the last time your child received 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.
Use of the physiological solution: you have applied it to your child.
Indication: Nose cleaning / Stuffy nose.
Overall for your child, how would you rate the effectiveness 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 your child.
Indication: Nose cleaning / Stuffy nose.
Overall for your child, after benefiting from the physiological solution would you say that your child had 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 your child.
Indication: Nose cleaning / Stuffy nose.
Overall, has the use of the physiological solution contributed to improving your child's 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 your child.
Indication: Nose cleaning / Stuffy nose.
On average,
when your child has 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 your child.
Indication: Nose cleaning / Stuffy nose.
Did your child experience any difficulties with the dose tip (hurtful or pain-inducing tip) when receiving 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 your child.
Indication: Nose cleaning / Stuffy nose.
Has your child tolerated 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 your child.
Indication: Nose cleaning / Runny nose.
Hidden
CAS3_Q1A_Q2C
Use of the physiological solution: you have applied it to your child.
Indication: Nose cleaning / Runny nose.
When was the last time your child received 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.
Use of the physiological solution: you have applied it to your child.
Indication: Nose cleaning / Runny nose.
Overall for your child, how would you rate the effectiveness 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 your child.
Indication: Nose cleaning / Runny nose.
Overall for your child, after benefiting from the physiological solution would you say that your child had 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 your child.
Indication: Nose cleaning / Runny nose.
Overall, has the use of the physiological solution contributed to improving your child's 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 your child.
Indication: Nose cleaning / Runny nose.
On average,
when your child has 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 your child.
Indication: Nose cleaning / Runny nose.
Did your child experience any difficulties with the dose tip (hurtful or pain-inducing tip) when receiving 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 your child.
Indication: Nose cleaning / Runny nose.
Has your child tolerated 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 your child.
Indication: Nose cleaning / Dry nose.
Hidden
CAS3_Q1A_Q2D
Use of the physiological solution: you have applied it to your child.
Indication: Nose cleaning / Dry nose.
When was the last time your child received 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.
Use of the physiological solution: you have applied it to your child.
Indication: Nose cleaning / Dry nose.
Overall for your child, how would you rate the effectiveness 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 your child.
Indication: Nose cleaning / Dry nose.
Overall for your child, after benefiting from the physiological solution would you say that your child had 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 your child.
Indication: Nose cleaning / Dry nose.
Overall, has the use of the physiological solution contributed to improving your child's 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 your child.
Indication: Nose cleaning / Dry nose.
On average,
when your child has 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 your child.
Indication: Nose cleaning / Dry nose.
Did your child experience any difficulties with the dose tip (hurtful or pain-inducing tip) when receiving 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 your child.
Indication: Nose cleaning / Dry nose.
Has your child tolerated 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 your child.
Indication: Nose cleaning / Frequent sneezing.
Hidden
CAS3_Q1A_Q2E
Use of the physiological solution: you have applied it to your child.
Indication: Nose cleaning / Frequent sneezing.
When was the last time your child received 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.
Use of the physiological solution: you have applied it to your child.
Indication: Nose cleaning / Frequent sneezing.
Overall for your child, how would you rate the effectiveness 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 your child.
Indication: Nose cleaning / Frequent sneezing.
Overall for your child, after benefiting from the physiological solution would you say that your child had 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 your child.
Indication: Nose cleaning / Frequent sneezing.
Overall, has the use of the physiological solution contributed to improving your child's 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 your child.
Indication: Nose cleaning / Frequent sneezing.
On average,
when your child has 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 your child.
Indication: Nose cleaning / Frequent sneezing.
Did your child experience any difficulties with the dose tip (hurtful or pain-inducing tip) when receiving 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 your child.
Indication: Nose cleaning / Frequent sneezing.
Has your child tolerated 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 your child.
Indication: Nose cleaning / Other.
Hidden
CAS3_Q1A_Q2F
Use of the physiological solution: you have applied it to your child.
Indication: Nose cleaning / Other.
When was the last time your child received 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.
Use of the physiological solution: you have applied it to your child.
Indication: Nose cleaning / Other.
Overall, has the use of the physiological solution contributed to improving your child's 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 your child.
Indication: Nose cleaning / Other.
On average,
when your child has 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 your child.
Indication: Nose cleaning / Other.
Did your child experience any difficulties with the dose tip (hurtful or pain-inducing tip) when receiving 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 your child.
Indication: Nose cleaning / Other.
Has your child tolerated 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
CAS3_Q1B
Use of the physiological solution: you have applied it to your child.
Your child have recently benefited from the physiological solution and you have applied it to your child
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 your child.
Indication: Eye cleaning / Daily eye hygiene.
Hidden
CAS3_Q1B_Q2A
Use of the physiological solution: you have applied it to your child.
Indication: Eye cleaning / Daily eye hygiene.
When was the last time your child received 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.
Use of the physiological solution: you have applied it to your child.
Indication: Eye cleaning / Daily eye hygiene.
Does your child wear contact lenses?
*
No
Yes
Use of the physiological solution: you have applied it to your child.
Indication: Eye cleaning / Daily eye hygiene.
Overall for your child, how would you rate the effectiveness 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 your child.
Indication: Eye cleaning / Daily eye hygiene.
Overall for your child, after benefiting from the physiological solution would you say that your child had 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 your child.
Indication: Eye cleaning / Daily eye hygiene.
Overall, has the use of the physiological solution contributed to improving your child's 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 your child.
Indication: Eye cleaning / Daily eye hygiene.
On average,
when your child has 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 your child.
Indication: Eye cleaning / Daily eye hygiene.
Did your child experience any difficulties with the dose tip (hurtful or pain-inducing tip) when receiving 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 your child.
Indication: Eye cleaning / Daily eye hygiene.
Has your child tolerated 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 your child.
Indication: Eye cleaning / Removal of contaminant/foreign body
Hidden
CAS3_Q1B_Q2B
Use of the physiological solution: you have applied it to your child.
Indication: Eye cleaning / Removal of contaminant/foreign body.
When was the last time your child received 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.
Use of the physiological solution: you have applied it to your child.
Indication: Eye cleaning / Removal of contaminant/foreign body.
Does your child wear contact lenses?
*
No
Yes
Use of the physiological solution: you have applied it to your child.
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 your child.
Indication: Eye cleaning / Removal of contaminant/foreign body.
Overall for your child, how would you rate the effectiveness 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 your child.
Indication: Eye cleaning / Removal of contaminant/foreign body.
Overall for your child, after benefiting from the physiological solution would you say that your child had 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 your child.
Indication: Eye cleaning / Removal of contaminant/foreign body.
Overall, has the use of the physiological solution contributed to improving your child's 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 your child.
Indication: Eye cleaning / Removal of contaminant/foreign body.
Did your child experience any difficulties with the dose tip (hurtful or pain-inducing tip) when receiving 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 your child.
Indication: Eye cleaning / Removal of contaminant/foreign body.
Has your child tolerated 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 your child.
Indication: Eye cleaning / Conjunctivitis.
Hidden
CAS3_Q1B_Q2BBIS
Use of the physiological solution: you have applied it to your child.
Indication: Eye cleaning / Conjunctivitis.
When was the last time your child received 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.
Use of the physiological solution: you have applied it to your child.
Indication: Eye cleaning / Conjunctivitis.
Does your child wear contact lenses?
*
No
Yes
Use of the physiological solution: you have applied it to your child.
Indication: Eye cleaning / Conjunctivitis.
Overall for your child, how would you rate the effectiveness 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 your child.
Indication: Eye cleaning / Conjunctivitis.
Overall for your child, after benefiting from the physiological solution would you say that your child had 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 your child.
Indication: Eye cleaning / Conjunctivitis.
Overall, has the use of the physiological solution contributed to improving your child's 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 your child.
Indication: Eye cleaning / Conjunctivitis.
On average,
when your child has 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 your child.
Indication: Eye cleaning / Conjunctivitis.
Did your child experience any difficulties with the dose tip (hurtful or pain-inducing tip) when receiving 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 your child.
Indication: Eye cleaning / Conjunctivitis.
Has your child tolerated 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 your child.
Indication: Eye cleaning / Other.
Hidden
CAS3_Q1B_Q2C
Use of the physiological solution: you have applied it to your child.
/br>
Indication: Eye cleaning / Other.
When was the last time your child received 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.
Use of the physiological solution: you have applied it to your child.
Indication: Eye cleaning / Other.
Does your child wear contact lenses?
*
No
Yes
Use of the physiological solution: you have applied it to your child.
Indication: Eye cleaning / Other.
Overall, has the use of the physiological solution contributed to improving your child's 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 your child.
Indication: Eye cleaning / Other.
On average,
when your child has 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 your child.
Indication: Eye cleaning / Other.
Did your child experience any difficulties with the dose tip (hurtful or pain-inducing tip) when receiving 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 your child.
Indication: Eye cleaning / Other.
Has your child tolerated 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
CAS3_Q1C
Use of the physiological solution: you have applied it to your child.
Your child have recently benefited from the physiological solution and you have applied it to your child
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 your child.
Indication: Ear cleaning / Daily Ear Hygiene.
Hidden
CAS1_Q1C_Q2A
Use of the physiological solution: you have applied it to your child.
Indication: Ear cleaning / Daily Ear Hygiene.
When was the last time your child received 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.
Use of the physiological solution: you have applied it to your child.
Indication: Ear cleaning / Daily Ear Hygiene.
Overall for your child, how would you rate the effectiveness 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 your child.
Indication: Ear cleaning / Daily Ear Hygiene.
Overall for your child, after benefiting from the physiological solution would you say that your child had 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 your child.
Indication: Ear cleaning / Daily Ear Hygiene.
Overall, has the use of the physiological solution contributed to improving your child's 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 your child.
Indication: Ear cleaning / Daily Ear Hygiene.
On average,
when your child has 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 your child.
Indication: Ear cleaning / Daily Ear Hygiene.
Did your child experience any difficulties with the dose tip (hurtful or pain-inducing tip) when receiving 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 your child.
Indication: Ear cleaning / Daily Ear Hygiene.
Has your child tolerated 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 your child.
Indication: Ear cleaning / Removal of excess earwax or foreign bodies.
Hidden
CAS3_Q1C_Q2B
Use of the physiological solution: you have applied it to your child.
Indication: Ear cleaning / Removal of excess earwax or foreign bodies.
When was the last time your child received 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.
Use of the physiological solution: you have applied it to your child.
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 your child.
Indication: Ear cleaning / Removal of excess earwax or foreign bodies.
Overall for your child, how would you rate the effectiveness 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 your child.
Indication: Ear cleaning / Removal of excess earwax or foreign bodies.
Overall for your child, after benefiting from the physiological solution would you say that your child had 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 your child.
Indication: Ear cleaning / Removal of excess earwax or foreign bodies.
Overall, has the use of the physiological solution contributed to improving your child's 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 your child.
Indication: Ear cleaning / Removal of excess earwax or foreign bodies.
Did your child experience any difficulties with the dose tip (hurtful or pain-inducing tip) when receiving 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 your child.
Indication: Ear cleaning / Removal of excess earwax or foreign bodies.
Has your child tolerated 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 your child.
Indication: Ear cleaning / Other.
Hidden
CAS3_Q1C_Q2C
Use of the physiological solution: you have applied it to your child.
Indication: Ear cleaning / Other.
When was the last time your child received 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.
Use of the physiological solution: you have applied it to your child.
Indication: Ear cleaning / Other.
Overall, has the use of the physiological solution contributed to improving your child's 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 your child.
Indication: Ear cleaning / Other.
On average,
when your child has 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 your child.
Indication: Ear cleaning / Other.
Did your child experience any difficulties with the dose tip (hurtful or pain-inducing tip) when receiving 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 your child.
Indication: Ear cleaning / Other.
Has your child tolerated 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
CAS3_Q1D
Use of the physiological solution: you have applied it to your child.
Your child have recently benefited from the physiological solution and you have applied it to your child
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 your child.
Indication: Cleaning a wound / Rinsing a wound without apparent contaminants.
Hidden
CAS3_Q1D_Q2A
Use of the physiological solution: you have applied it to your child.
Indication: Cleaning a wound / Rinsing a wound without apparent contaminants.
When was the last time your child received 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.
Use of the physiological solution: you have applied it to your child.
Indication: Cleaning a wound / Rinsing a wound without apparent contaminants.
Overall for your child, how would you rate the effectiveness 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 your child.
Indication: Cleaning a wound / Rinsing a wound without apparent contaminants.
Overall for your child, after benefiting from the physiological solution would you say that your child had 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 your child.
Indication: Cleaning a wound / Rinsing a wound without apparent contaminants.
Overall, has the use of the physiological solution contributed to improving your child's 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 your child.
Indication: Cleaning a wound / Rinsing a wound without apparent contaminants.
On average,
when your child has 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 your child.
Indication: Cleaning a wound / Rinsing a wound without apparent contaminants.
Did your child experience any difficulties with the dose tip (hurtful or pain-inducing tip) when receiving 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 your child.
Indication: Cleaning a wound / Rinsing a wound without apparent contaminants.
During the period in which your child's 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 your child.
Indication: Cleaning a wound / Rinsing a wound without apparent contaminants.
Has your child tolerated 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 your child.
Indication: Cleaning a wound / Rinsing a wound with apparent contaminants.
Hidden
CAS3_Q1D_Q2B
Use of the physiological solution: you have applied it to your child.
Indication: Cleaning a wound / Rinsing a wound with apparent contaminants.
When was the last time your child received 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.
Use of the physiological solution: you have applied it to your child.
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 your child.
Indication: Cleaning a wound / Rinsing a wound with apparent contaminants.
Overall for your child, how would you rate the effectiveness 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 your child.
Indication: Cleaning a wound / Rinsing a wound with apparent contaminants.
Overall for your child, after benefiting from the physiological solution would you say that your child had 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 your child.
Indication: Cleaning a wound / Rinsing a wound with apparent contaminants.
Overall, has the use of the physiological solution contributed to improving your child's 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 your child.
Indication: Cleaning a wound / Rinsing a wound with apparent contaminants.
Did your child experience any difficulties with the dose tip (hurtful or pain-inducing tip) when receiving 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 your child.
Indication: Cleaning a wound / Rinsing a wound with apparent contaminants.
Has your child tolerated 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 your child.
Indication: Cleaning a wound / Other.
Hidden
CAS3_Q1D_Q2C
Use of the physiological solution: you have applied it to your child.
Indication: Cleaning a wound / Other.
When was the last time your child received 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.
Use of the physiological solution: you have applied it to your child.
Indication: Cleaning a wound / Other.
Overall, has the use of the physiological solution contributed to improving your child's 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 your child.
Indication: Cleaning a wound / Other.
On average,
when your child has 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 your child.
Indication: Cleaning a wound / Other.
Did your child experience any difficulties with the dose tip (hurtful or pain-inducing tip) when receiving 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 your child.
Indication: Cleaning a wound / Other.
Has your child tolerated 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
CAS3_Q1E
Use of the physiological solution: you have applied it to your child.
Your child have recently benefited from the physiological solution and you have applied it to your child
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 your child.
Indication: Inhalation (aerosol therapy) / Humidification breathing to facilitate evacuation of bronchial secretions.
Hidden
CAS3_Q1E_Q2A
Use of the physiological solution: you have applied it to your child.
Indication: Inhalation (aerosol therapy) / Humidification breathing to facilitate evacuation of bronchial secretions.
When was the last time your child received 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.
Use of the physiological solution: you have applied it to your child.
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 your child.
Indication: Inhalation (aerosol therapy) / Humidification breathing to facilitate evacuation of bronchial secretions.
Overall for your child, how would you rate the effectiveness 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 your child.
Indication: Inhalation (aerosol therapy) / Humidification breathing to facilitate evacuation of bronchial secretions.
Overall for your child, after benefiting from the physiological solution would you say that your child had 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 your child.
Indication: Inhalation (aerosol therapy) / Humidification breathing to facilitate evacuation of bronchial secretions.
Overall, has the use of the physiological solution contributed to improving your child's 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 your child.
Indication: Inhalation (aerosol therapy) / Humidification breathing to facilitate evacuation of bronchial secretions.
On average,
when your child has 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 your child.
Indication: Inhalation (aerosol therapy) / Humidification breathing to facilitate evacuation of bronchial secretions.
Has your child tolerated 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 your child.
Indication: Inhalation (aerosol therapy) / Dilution of an inhalation drug.
Hidden
CAS3_Q1E_Q2B
Use of the physiological solution: you have applied it to your child.
Indication: Inhalation (aerosol therapy) / Dilution of an inhalation drug.
When was the last time your child received 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.
Use of the physiological solution: you have applied it to your child.
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 your child.
Indication: Inhalation (aerosol therapy) / Dilution of an inhalation drug.
On average,
when your child has 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 your child.
Indication: Inhalation (aerosol therapy) / Other.
Hidden
CAS3_Q1E_Q2C
Use of the physiological solution: you have applied it to your child.
Indication: Inhalation (aerosol therapy) / Other.
When was the last time your child received 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.
Use of the physiological solution: you have applied it to your child.
Indication: Inhalation (aerosol therapy) / Other.
Specify the brand and model of the nebulizer used:
*
Use of the physiological solution: you have applied it to your child.
Indication: Inhalation (aerosol therapy) / Other.
Overall, has the use of the physiological solution contributed to improving your child's 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 your child.
Indication: Inhalation (aerosol therapy) / Other.
On average,
when your child has 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 your child.
Indication: Inhalation (aerosol therapy) / Other.
Has your child tolerated 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.
