Adverse Reaction Form

INFORMATION ABOUT THE CUSTOMER WHO HAD THE ADVERSE REACTION

Name

Surname

Age

Gender

Male

Female

Do not specify

Nationality

Do you suffer from allergies? YES / NO

SINO

If YES, which ones?

Are you taking any medications/supplements/other cosmetics? YES / NO

SINO

If YES, which ones?

If YES, frequency of use: n° times per day.

COSMETIC PRODUCT

Brand

Product

Lot

First use date

Last use date

Frequency of use: n° times per day

Had the product been used before? YES / NO

SINO

INFORMATION ON SUSPECTED ADVERSE REACTIONS

Seriousness

Mild

Moderate

Severe

Very severe

Reaction Onset Date

Area of the body where the reaction occurred

Was the use of the product discontinued after the undesirable effect? YES / NO

SINO

If YES, has the reaction improved? YES / NO

SINO

Has the product been used again? YES / NO

SINO

In the same way? YES / NO

SINO

If YES, did the effect recur? YES / NO

SINO

ADVERSE REACTIONS RESULT

Outcome

Resolution

Improvement

Still in progress

Were any tests performed? YES / NO

SINO

INFORMATION ABOUT THE FORM COMPILER

The same one who had the adverse reaction? YES / NO

SINO

Name

Surname

Mail

Phone

Attach product photo and reaction if possible

I authorize the processing of my personal identification data in the manner and for the purposes indicated in the privacy policy.