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Surveillance Questionnaire for Medical Device

Product Name

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?

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)?

Signed

Date

Additional Comments