Surveillance Questionnaire for Medical Device

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Surveillance Questionnaire for Medical Device

Product Name

1) Age:

0-1 1-3 3-6 6-12 12-18 18-30 30-50 50-70 >70

2) Sex:

Male Female

3) How long did you take the product?

1-3 Days 4-6 Days 7-14 Days 15-30 Days

4) How do you rate the overall characteristics of the product?

4 (much better than expected) 3 (slightly better than expected) 2 (Just as expected) 1 (Slightly worse than expected) 0 (worse than expected)

5) Time of improvement from symptoms

After a few minutes After a few hours 1-3 Days 4-6 Days 7-14 Days 15-30 Days

6) Did you observe side effects?

No Yes, listed in the leaflet Yes, other not listed in the leaflet

7) How did you find the leaflet of the product (indications, mode of use, side effects, contraindications)?

Very clear Clear enogh Unclear

8) How did you rate the ease of use of the product (simplicity of intake)?

4 (much better than expected) 3 (slightly better than expected) 2 (Just as expected) 1 (Slightly worse than expected) 0 (worse than expected)

Signed

Date

Additional Comments

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CF Pharma Unit 73 Hebron
Industrial Estate Kilkenny
Ireland, R95 CRK2

info@cfpharma.ie

+353 (0)56 7799410

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