Thousandlashes Adverse Effect Questionnaire (1)

Thousandlashes Adverse Effect Questionnaire
Section A- Consumer/Contact Information
Reporting Person’s Name *

First NameLast Name
Reporting Person's Contact Phone Number*
Format: (000) 000-0000.
Reporting Person’s Email*
example@example.com
Todays Date*

MonthDayYear
Date
Name Of Person Effected*
Effected Person’s Contact Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Effected Person’s Email*
example@example.com
Was the person effected taking any medications, OTC drugs, or supplements at time of use? If yes, please list below
List any known and preexisting allergies and/or medical conditions of the effected person.
Name Of Person Who Administered Product On Effected Person (If Applicable)
Cosmetology/Esthetician License State (If Applicable)
Cosmetology/Esthetician License Number (If Applicable)
Section B- Details Of Event
Thousandlashes Product(s) Used
List other brands and Products Used directly before, during, or directly after application of Thousandlashes products
Add url Links to other brands used
Date products were used

MonthDayYear
Date
Describe how the product was used (list all products and techniques used before during and after application of the listed product(s)
What kind of problem was it? (Check all that apply)

Were hurt or had a bad side effect (including new or worsening symptoms)Used a product incorrectly which could have or led to a problemNoticed a problem with the quality of the product 9Had problems after switching from one product maker to another maker
Did any of the following happen? (Check all that apply)

Hospitalization – admitted or stayed longer Required help to prevent permanent harmDisability or health problemBirth defectLife-threatening Death (include date) (e.g., 01-Jan-1900):Other
Date Adverse Side Effect Occurred

MonthDayYear
Tell us what happened (please give an accurate account of what occurred, in chronological order, to the best of your ability.)
Section C – Product Availability
Do you still have the product in case we need to evaluate it?*

YesNo
Do you have a picture of the Thousandlashes product(s)? (If yes, please include a picture)*

YesNo
Upload documents

Cancelof
Section D - Relevant Tests/Laboratory Data
Test Date

MonthDayYear
Date
Test Name:
Test Result:
Upload Medical Records

Cancelof
Additional Comments:
Your health information cannot be used or shared without your written permission unless the
law allows it. Please use the following link for more information on the HIPAA Privacy Rule:

https://www.fda.gov/safety/reporting-serious-problems-fda/hipaa-compliance-reporters-fda-medwatch
How would you like us to contact you? (Check all that apply)*

EmailPhone
Should be Empty:

Thousandlashes Adverse Effect Questionnaire

Section A- Consumer/Contact Information

Section B- Details Of Event

Section C – Product Availability

Section D - Relevant Tests/Laboratory Data