ID
Hidden
CA1
*
Hidden
CA2
*
Hidden
CA3
*
Hidden
CA4
*
Hidden
SE
*
Please click next to continue.
Use of the physiological solution: your child has used it alone.
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
CAS4_Q1A
Use of the physiological solution: your child has used it alone.
Your child have recently benefited from the physiological solution and has used it alone
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: your child has used it alone.
Indication : Nose cleaning / Daily nose hygiene.
Hidden
CAS4_Q1A_Q2A
Use of the physiological solution: your child has used it alone.
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: your child has used it alone.
Indication: Nose cleaning / Daily nose hygiene.
Overall, how would your child 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: your child has used it alone.
Indication: Nose cleaning / Daily nose hygiene.
Overall, after benefiting from the physiological solution, 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: your child has used it alone.
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: your child has used it alone.
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: your child has used it alone.
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: your child has used it alone.
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: your child has used it alone.
Indication: Nose cleaning / Stuffy nose.
Hidden
CAS4_Q1A_Q2B
Use of the physiological solution: your child has used it alone.
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: your child has used it alone.
Indication: Nose cleaning / Stuffy nose.
Overall, how would your child 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: your child has used it alone.
Indication: Nose cleaning / Stuffy nose.
Overall, after benefiting from the physiological solution, 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: your child has used it alone.
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: your child has used it alone.
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: your child has used it alone.
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: your child has used it alone.
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: your child has used it alone.
Indication: Nose cleaning / Runny nose.
Hidden
CAS4_Q1A_Q2C
Use of the physiological solution: your child has used it alone.
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: your child has used it alone.
Indication: Nose cleaning / Runny nose.
Overall, how would your child 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: your child has used it alone.
Indication: Nose cleaning / Runny nose.
Overall, after benefiting from the physiological solution, 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: your child has used it alone.
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: your child has used it alone.
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: your child has used it alone.
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: your child has used it alone.
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: your child has used it alone.
Indication: Nose cleaning / Dry nose.
Hidden
CAS4_Q1A_Q2D
Use of the physiological solution: your child has used it alone.
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: your child has used it alone.
Indication: Nose cleaning / Dry nose.
Overall, how would your child 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: your child has used it alone.
Indication: Nose cleaning / Dry nose.
Overall, after benefiting from the physiological solution, 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: your child has used it alone.
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: your child has used it alone.
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: your child has used it alone.
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: your child has used it alone.
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: your child has used it alone.
Indication: Nose cleaning / Frequent sneezing.
Hidden
CAS4_Q1A_Q2E
Use of the physiological solution: your child has used it alone.
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: your child has used it alone.
Indication: Nose cleaning / Frequent sneezing.
Overall, how would your child 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: your child has used it alone.
Indication: Nose cleaning / Frequent sneezing.
Overall, after benefiting from the physiological solution, 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: your child has used it alone.
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: your child has used it alone.
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: your child has used it alone.
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: your child has used it alone.
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: your child has used it alone.
Indication: Nose cleaning / Other.
Hidden
CAS4_Q1A_Q2F
Use of the physiological solution: your child has used it alone.
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: your child has used it alone.
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: your child has used it alone.
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: your child has used it alone.
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: your child has used it alone.
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
CAS4_Q1B
Use of the physiological solution: your child has used it alone.
Your child have recently benefited from the physiological solution and has used it alone
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: your child has used it alone.
Indication: Eye cleaning / Daily eye hygiene.
Hidden
CAS4_Q1B_Q2A
Use of the physiological solution: your child has used it alone.
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: your child has used it alone.
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, how would your child 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: your child has used it alone.
Indication: Eye cleaning / Daily eye hygiene.
Overall, after benefiting from the physiological solution, 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: your child has used it alone.
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: your child has used it alone.
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: your child has used it alone.
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: your child has used it alone.
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: your child has used it alone.
Indication: Eye cleaning / Removal of contaminant/foreign body
Hidden
CAS4_Q1B_Q2B
Use of the physiological solution: your child has used it alone.
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: your child has used it alone.
Indication: Eye cleaning / Removal of contaminant/foreign body.
Does your child wear contact lenses?
*
No
Yes
Use of the physiological solution: your child has used it alone.
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: your child has used it alone.
Indication: Eye cleaning / Removal of contaminant/foreign body.
Overall, how would your child 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: your child has used it alone.
Indication: Eye cleaning / Removal of contaminant/foreign body.
Overall, after benefiting from the physiological solution, 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: your child has used it alone.
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: your child has used it alone.
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: your child has used it alone.
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: your child has used it alone.
Indication: Eye cleaning / Conjunctivitis.
Hidden
CAS4_Q1B_Q2BBIS
Use of the physiological solution: your child has used it alone.
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: your child has used it alone.
Indication: Eye cleaning / Conjunctivitis.
Does your child wear contact lenses?
*
No
Yes
Use of the physiological solution: your child has used it alone.
Indication: Eye cleaning / Conjunctivitis.
Overall, how would your child 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: your child has used it alone.
Indication: Eye cleaning / Conjunctivitis.
Overall, after benefiting from the physiological solution, 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: your child has used it alone.
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: your child has used it alone.
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: your child has used it alone.
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: your child has used it alone.
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: your child has used it alone.
Indication: Eye cleaning / Other.
Hidden
CAS4_Q1B_Q2C
Use of the physiological solution: your child has used it alone.
/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: your child has used it alone.
Indication: Eye cleaning / Other.
Does your child wear contact lenses?
*
No
Yes
Use of the physiological solution: your child has used it alone.
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: your child has used it alone.
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: your child has used it alone.
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: your child has used it alone.
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
CAS4_Q1C
Use of the physiological solution: your child has used it alone.
Your child have recently benefited from the physiological solution and has used it alone
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: your child has used it alone.
Indication: Ear cleaning / Daily Ear Hygiene.
Hidden
CAS4_Q1C_Q2A
Use of the physiological solution: your child has used it alone.
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: your child has used it alone.
Indication: Ear cleaning / Daily Ear Hygiene.
Overall, how would your child 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: your child has used it alone.
Indication: Ear cleaning / Daily Ear Hygiene.
Overall, after benefiting from the physiological solution, 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: your child has used it alone.
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: your child has used it alone.
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: your child has used it alone.
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: your child has used it alone.
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: your child has used it alone.
Indication: Ear cleaning / Removal of excess earwax or foreign bodies.
Hidden
CAS4_Q1C_Q2B
Use of the physiological solution: your child has used it alone.
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: your child has used it alone.
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: your child has used it alone.
Indication: Ear cleaning / Removal of excess earwax or foreign bodies.
Overall, how would your child 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: your child has used it alone.
Indication: Ear cleaning / Removal of excess earwax or foreign bodies.
Overall, after benefiting from the physiological solution, 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: your child has used it alone.
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: your child has used it alone.
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: your child has used it alone.
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: your child has used it alone.
Indication: Ear cleaning / Other.
Hidden
CAS4_Q1C_Q2C
Use of the physiological solution: your child has used it alone.
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: your child has used it alone.
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: your child has used it alone.
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: your child has used it alone.
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: your child has used it alone.
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
CAS4_Q1D
Use of the physiological solution: your child has used it alone.
Your child have recently benefited from the physiological solution and has used it alone
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: your child has used it alone.
Indication: Cleaning a wound / Rinsing a wound without apparent contaminants.
Hidden
CAS4_Q1D_Q2A
Use of the physiological solution: your child has used it alone.
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: your child has used it alone.
Indication: Cleaning a wound / Rinsing a wound without apparent contaminants.
Overall, how would your child 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: your child has used it alone.
Indication: Cleaning a wound / Rinsing a wound without apparent contaminants.
Overall, after benefiting from the physiological solution, 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: your child has used it alone.
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: your child has used it alone.
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: your child has used it alone.
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: your child has used it alone.
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: your child has used it alone.
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: your child has used it alone.
Indication: Cleaning a wound / Rinsing a wound with apparent contaminants.
Hidden
CAS4_Q1D_Q2B
Use of the physiological solution: your child has used it alone.
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: your child has used it alone.
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: your child has used it alone.
Indication: Cleaning a wound / Rinsing a wound with apparent contaminants.
Overall, how would your child 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: your child has used it alone.
Indication: Cleaning a wound / Rinsing a wound with apparent contaminants.
Overall, after benefiting from the physiological solution, 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: your child has used it alone.
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: your child has used it alone.
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: your child has used it alone.
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: your child has used it alone.
Indication: Cleaning a wound / Other.
Hidden
CAS4_Q1D_Q2C
Use of the physiological solution: your child has used it alone.
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: your child has used it alone.
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: your child has used it alone.
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: your child has used it alone.
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: your child has used it alone.
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
CAS4_Q1E
Use of the physiological solution: your child has used it alone.
Your child have recently benefited from the physiological solution and has used it alone
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: your child has used it alone.
Indication: Inhalation (aerosol therapy) / Humidification breathing to facilitate evacuation of bronchial secretions.
Hidden
CAS4_Q1E_Q2A
Use of the physiological solution: your child has used it alone.
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: your child has used it alone.
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: your child has used it alone.
Indication: Inhalation (aerosol therapy) / Humidification breathing to facilitate evacuation of bronchial secretions.
Overall, how would your child 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: your child has used it alone.
Indication: Inhalation (aerosol therapy) / Humidification breathing to facilitate evacuation of bronchial secretions.
Overall, after benefiting from the physiological solution, 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: your child has used it alone.
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: your child has used it alone.
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: your child has used it alone.
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: your child has used it alone.
Indication: Inhalation (aerosol therapy) / Dilution of an inhalation drug.
Hidden
CAS4_Q1E_Q2B
Use of the physiological solution: your child has used it alone.
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: your child has used it alone.
Indication: Inhalation (aerosol therapy) / Dilution of an inhalation drug.
Specify the brand and model of the nebulizer used:
*
Use of the physiological solution: your child has used it alone.
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: your child has used it alone.
Indication: Inhalation (aerosol therapy) / Other.
Hidden
CAS4_Q1E_Q2C
Use of the physiological solution: your child has used it alone.
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: your child has used it alone.
Indication: Inhalation (aerosol therapy) / Other.
Specify the brand and model of the nebulizer used:
*
Use of the physiological solution: your child has used it alone.
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: your child has used it alone.
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: your child has used it alone.
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.
