Questionnaire FormRemeCure2024-10-27T08:17:04+00:00 Information about the patient: Full Name: Age: Address: Telephone: Email: Information about the suspected product: Trade Name: Generic Name: Dosage (If possible): Category: —Please choose an option—Food SupplementsPharmaCureMicro-PelletsRemeScentGummiCureSilicone Sheets Manufacturer: Information on the appointment of the suspected product: The suspected product was prescribed by a doctor: YesNo The patient used the product without prescription: YesNo Describe any clinical presentation of adverse reactions to the product, or any signs indicating lack of efficacy of the product: Information about the informant: Name: Address: Telephone: Email: Information about the doctor, health care facility and place of residence of the patient: Name: Location: Country: City: Telephone: Email: Fax:
