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Argentina
Bolivia
Brazil
Chile
Colombia
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Paraguay
Peru
Uruguay
Venezuela
Mexico
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Costa Rica
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I am...
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Are you linked to a health institution or hospital?
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Which institution?
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Patient
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Gender
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Pregnant?
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Date of last period
How many gestational weeks?
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Age
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Product
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Why do you use
Administration route
How it is used (quantity and how many times a day)
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Patient's clinical history
Does the patient have any disease?
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Disease name
Diagnosis date
Does the patient use any other medication?
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Please list other adverse events below, if any
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Adverse Effects (AE)
Describe here the history of the event:
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Adverse Effects (AE)
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Start date
*
Has recovered?
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Recovery date
Were the AEs treated?
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Which treatment?
Presented others Adverse Effects?
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Add adverse event
Continued?
Yes
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Were the AEs treated?
Yes
No
Which treatment?
Suspended the medication use due to the AEs?
Yes
No
* Dear, based on your report, we may need additional information to deal with your case. Do you authorize us to contact you by email or phone?
Yes, i authorize
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I accept contact in both
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