Questionnaire for collecting information about an adverse effect of a cosmetic product.

    Date of submission
    Consumer:
    Full Name
    Contact details (phone, messenger, email)
    Gender
    Age
    Basic characteristics, including relevant medical history and previous use of the cosmetic product (e.g., history of allergies, previous reaction to a cosmetic product)
    Reporter: (if different from consumer/end user):
    Full Name
    Contact details (phone, messenger, email)
    Qualification (e.g., doctor, dentist, pharmacist, nurse, consumer, or another non-medical reporter)
    As much as possible, provide information: basic characteristics of the consumer, including relevant medical history and previous use of the cosmetic product (e.g., history of allergies, previous reaction to a cosmetic product)
    Suspected product:
    Product category
    Exact name
    Batch number (if available)
    Conditions of use:
    Duration of use
    In case of product misuse (e.g., incorrect usage), sequence of events leading to the error
    Adverse effect:
    Signs/symptoms
    Chronology (date of event onset, time to appearance/disappearance of signs or symptoms)
    Severity of the event/effect
    Diagnosis by a healthcare professional (if available)
    Medical examination results (if available)
    Results of repeated application (if available)
    Clinical course of the event, including medical treatment if applicable