{"id":679,"date":"2019-03-19T17:35:07","date_gmt":"2019-03-19T17:35:07","guid":{"rendered":"https:\/\/estedi.es\/?page_id=679"},"modified":"2019-03-26T13:09:27","modified_gmt":"2019-03-26T13:09:27","slug":"reacciones-adversas","status":"publish","type":"page","link":"https:\/\/estedi.es\/en\/reacciones-adversas\/","title":{"rendered":"Adverse reactions"},"content":{"rendered":"<div class=\"wpb-content-wrapper\" id=\"wpb-content-root\"><p>[vc_row full_width=&#8221;stretch_row&#8221;][vc_column][vc_column_text css_animation=&#8221;top-to-bottom&#8221;]<\/p>\n<p style=\"text-align: justify;\">If you (or someone known) has had a side effect to one of our medications, you can notify us directly by filling out the form below.<\/p>\n<p style=\"text-align: justify;\">The information that you provide us can help us in our work to identify the side effects not previously recognized and, therefore, improve the safe use of medications. We encourage you to also notify the side effects that are described in the package leaflet.<\/p>\n<p style=\"text-align: justify;\">Thank you very much for your help.<br \/>\n<strong>Laboratorios ESTEDI S.L.<\/strong><\/p>\n<p>[\/vc_column_text][vc_column_text css_animation=&#8221;left-to-right&#8221; css=&#8221;.vc_custom_1553605757996{padding-top: 60px !important;padding-bottom: 60px !important;}&#8221;]<\/p>\n<h2 style=\"text-align: center;\"><span style=\"text-decoration: underline;\">FORM to notify ADVERSE REACTIONS<\/span><\/h2>\n<p>[\/vc_column_text]<div role=\"form\" class=\"wpcf7\" id=\"wpcf7-f678-o3\" lang=\"es-ES\" dir=\"ltr\">\n<div class=\"screen-reader-response\"><\/div>\n<form action=\"\/en\/wp-json\/wp\/v2\/pages\/679#wpcf7-f678-o3\" method=\"post\" class=\"wpcf7-form\" novalidate=\"novalidate\">\n<div style=\"display: none;\">\n<input type=\"hidden\" name=\"_wpcf7\" value=\"678\" \/>\n<input type=\"hidden\" name=\"_wpcf7_version\" value=\"4.9.2\" \/>\n<input type=\"hidden\" name=\"_wpcf7_locale\" value=\"es_ES\" \/>\n<input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f678-o3\" \/>\n<input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_hidden_group_fields\" value=\"\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_hidden_groups\" value=\"\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_visible_groups\" value=\"\" \/>\n<input type=\"hidden\" name=\"_wpcf7cf_options\" value=\"{&quot;form_id&quot;:678,&quot;conditions&quot;:[{&quot;then_field&quot;:&quot;grupo_enfermedades-previas-2&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;radio-370&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;S\\u00ed&quot;}]},{&quot;then_field&quot;:&quot;grupo_enfermedades-previas-3&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;radio-2370&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;S\\u00ed&quot;}]},{&quot;then_field&quot;:&quot;grupo_enfermedades-previas-4&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;radio-3370&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;S\\u00ed&quot;}]},{&quot;then_field&quot;:&quot;grupo_enfermedades-previas-5&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;radio-4370&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;S\\u00ed&quot;}]},{&quot;then_field&quot;:&quot;grupo_ram-2&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;radio-1858&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;S\\u00ed&quot;}]},{&quot;then_field&quot;:&quot;grupo_ram-3&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;radio-221858&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;S\\u00ed&quot;}]},{&quot;then_field&quot;:&quot;grupo_ram-4&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;radio-331858&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;S\\u00ed&quot;}]},{&quot;then_field&quot;:&quot;grupo_ram-5&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;radio-441858&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;S\\u00ed&quot;}]},{&quot;then_field&quot;:&quot;grupo_medicamento-2&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;radio-1178910&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;S\\u00ed&quot;}]},{&quot;then_field&quot;:&quot;grupo_medicamento-3&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;radio-2278910&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;S\\u00ed&quot;}]},{&quot;then_field&quot;:&quot;grupo_medicamento-4&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;radio-3378910&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;S\\u00ed&quot;}]},{&quot;then_field&quot;:&quot;grupo_medicamento-5&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;radio-4478910&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;S\\u00ed&quot;}]}],&quot;settings&quot;:false}\" \/>\n<\/div>\n<p><script language=\"javascript\">var ua = window.navigator.userAgent;var msie = ua.indexOf('MSIE ');var trident = ua.indexOf('Trident\/');if (msie  > 0 || trident > 0) {alert(\"Desde Estedi te informamos que este formulario web no funciona correctamente con navegadores antiguos, como es el INTERNET EXPLORER.\\n\\nSi quieres notificarnos una reacci\u00f3n adversa por favor utiliza otro navegador m\u00e1s moderno como por ej. GOOGLE CHROME, MOZILLA FIREFOX o MICROSOFT EDGE.\\n\\nMuchas gracias por tu comprensi\u00f3n y disculpa las molestias.\\n\\nLaboratorios ESTEDI S.L.\");}<\/script><\/p>\n<h3><strong>PATIENT'S DATA*<\/strong><\/h3>\n<div class='content-column full_width'><div style=\"padding-bottom:10px;\">Sex:<br \/>\n<span class=\"wpcf7-form-control-wrap your-browser-sexo\"><select name=\"your-browser-sexo\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"\">---<\/option><option value=\"Man\">Man<\/option><option value=\"Woman\">Woman<\/option><option value=\"Unknown\">Unknown<\/option><\/select><\/span><\/div><\/div>\n<div class='content-column one_half'><div style=\"padding-top:30px;padding-right:10px;\">Age:<span class=\"wpcf7-form-control-wrap number-114\"><input type=\"number\" name=\"number-114\" value=\"\" class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-required wpcf7-validates-as-number\" min=\"0\" max=\"150\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Type your age using the side selector\" \/><\/span><\/div><\/div>\n<div class='content-column one_half last_column'><div style=\"\">Indicate the correct unit for the AGE that you have entered, tell us if you are talking about:<br \/>\n<span class=\"wpcf7-form-control-wrap your-browser-unidades-edad\"><select name=\"your-browser-unidades-edad\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"\">---<\/option><option value=\"Hours\">Hours<\/option><option value=\"Days\">Days<\/option><option value=\"Months\">Months<\/option><option value=\"Years\">Years<\/option><\/select><\/span><\/div><\/div><div class='clear_column'><\/div>\n<div class='content-column full_width'><div style=\"padding-top:20px;padding-right:10px;\">Enter date of birth:  &nbsp;<span class=\"wpcf7-form-control-wrap date-552\"><input type=\"date\" name=\"date-552\" value=\"\" class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date\" aria-invalid=\"false\" \/><\/span><\/div><\/div>\n<div class='content-column one_third'><div style=\"padding-top:10px;padding-right:10px;\">Age group:<br \/>\n<span class=\"wpcf7-form-control-wrap your-browser-grupo-de-edad\"><select name=\"your-browser-grupo-de-edad\" class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\"><option value=\"\">---<\/option><option value=\"Fetus\">Fetus<\/option><option value=\"Newborn\">Newborn<\/option><option value=\"Infant\">Infant<\/option><option value=\"Boy\">Boy<\/option><option value=\"Teen\">Teen<\/option><option value=\"Adult\">Adult<\/option><option value=\"65 years old or over 65\">65 years old or over 65<\/option><\/select><\/span><\/div><\/div>\n<div class='content-column one_third'><div style=\"padding-top:10px;padding-right:10px;\">Weight (Kg):<br \/>\n<span class=\"wpcf7-form-control-wrap number-262\"><input type=\"number\" name=\"number-262\" value=\"\" class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-number\" min=\"0\" max=\"500\" aria-invalid=\"false\" placeholder=\"Enter your weight\" \/><\/span><\/div><\/div>\n<div class='content-column one_third last_column'><div style=\"padding-top:10px;padding-right:10px;\">Height (cm):<br \/>\n<span class=\"wpcf7-form-control-wrap number-263\"><input type=\"number\" name=\"number-263\" value=\"\" class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-number\" min=\"0\" max=\"300\" aria-invalid=\"false\" placeholder=\"Enter your height\" \/><\/span><\/div><\/div><div class='clear_column'><\/div>\n<h6>*Please, select at least 2 boxes of the above, thank you.<\/h6>\n<h3><strong>PREVIOUS OR CURRENT DISEASES<\/strong><\/h3>\n<div class='content-column full_width'><div style=\"\">Enter disease: <span class=\"wpcf7-form-control-wrap text-697\"><input type=\"text\" name=\"text-697\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span><\/div><\/div>\n<div class='content-column one_half'><div style=\"padding-top:20px;\">Start date: <span class=\"wpcf7-form-control-wrap date-254\"><input type=\"date\" name=\"date-254\" value=\"\" class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date\" aria-invalid=\"false\" \/><\/span><\/div><\/div>\n<div class='content-column one_half last_column'><div style=\"padding-top:20px;\">Ending date: <span class=\"wpcf7-form-control-wrap date-255\"><input type=\"date\" name=\"date-255\" value=\"\" class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date\" aria-invalid=\"false\" \/><\/span><\/div><\/div><div class='clear_column'><\/div>\n<div class='content-column full_width'><div style=\"padding-top:20px;\">Comments: <span class=\"wpcf7-form-control-wrap textarea-204\"><textarea name=\"textarea-204\" cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\"><\/textarea><\/span><\/div><\/div>\n<div class='content-column full_width'><div style=\"padding-top:20px;\">Do you wish to add another disease? <span class=\"wpcf7-form-control-wrap radio-370\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-370\" value=\"S\u00ed\" \/><span class=\"wpcf7-list-item-label\">S\u00ed<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-370\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span><\/div><\/div>\n<div id=\"grupo_enfermedades-previas-2\" data-clear_on_hide data-class=\"wpcf7cf_group\">\n<div class='content-column full_width'><div style=\"padding-top:20px;\">Enter disease n\u00ba2: <span class=\"wpcf7-form-control-wrap text-2697\"><input type=\"text\" name=\"text-2697\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span><\/div><\/div>\n<div class='content-column one_half'><div style=\"padding-top:20px;\">Start date: <span class=\"wpcf7-form-control-wrap date-2254\"><input type=\"date\" name=\"date-2254\" value=\"\" class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date\" aria-invalid=\"false\" \/><\/span><\/div><\/div>\n<div class='content-column one_half last_column'><div style=\"padding-top:20px;\">Ending date: <span class=\"wpcf7-form-control-wrap date-2255\"><input type=\"date\" name=\"date-2255\" value=\"\" class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date\" aria-invalid=\"false\" \/><\/span><\/div><\/div><div class='clear_column'><\/div>\n<div class='content-column full_width'><div style=\"padding-top:20px;\">Comments: <span class=\"wpcf7-form-control-wrap textarea-2204\"><textarea name=\"textarea-2204\" cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\"><\/textarea><\/span><\/div><\/div>\n<div class='content-column full_width'><div style=\"padding-top:20px;\">Do you wish to add another disease? <span class=\"wpcf7-form-control-wrap radio-2370\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-2370\" value=\"S\u00ed\" \/><span class=\"wpcf7-list-item-label\">S\u00ed<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-2370\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span><\/div><\/div><\/div>\n<div id=\"grupo_enfermedades-previas-3\" data-clear_on_hide data-class=\"wpcf7cf_group\">\n<div class='content-column full_width'><div style=\"padding-top:20px;\">Enter disease n\u00ba3: <span class=\"wpcf7-form-control-wrap text-3697\"><input type=\"text\" name=\"text-3697\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span><\/div><\/div>\n<div class='content-column one_half'><div style=\"padding-top:20px;\">Start date: <span class=\"wpcf7-form-control-wrap date-3254\"><input type=\"date\" name=\"date-3254\" value=\"\" class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date\" aria-invalid=\"false\" \/><\/span><\/div><\/div>\n<div class='content-column one_half last_column'><div style=\"padding-top:20px;\">Ending date: <span class=\"wpcf7-form-control-wrap date-3255\"><input type=\"date\" name=\"date-3255\" value=\"\" class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date\" aria-invalid=\"false\" \/><\/span><\/div><\/div><div class='clear_column'><\/div>\n<div class='content-column full_width'><div style=\"padding-top:20px;\">Comments: <span class=\"wpcf7-form-control-wrap textarea-3204\"><textarea name=\"textarea-3204\" cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\"><\/textarea><\/span><\/div><\/div>\n<div class='content-column full_width'><div style=\"padding-top:20px;\">Do you wish to add another disease? <span class=\"wpcf7-form-control-wrap radio-3370\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-3370\" value=\"S\u00ed\" \/><span class=\"wpcf7-list-item-label\">S\u00ed<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-3370\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span><\/div><\/div><\/div>\n<div id=\"grupo_enfermedades-previas-4\" data-clear_on_hide data-class=\"wpcf7cf_group\">\n<div class='content-column full_width'><div style=\"padding-top:20px;\">Enter disease n\u00ba4: <span class=\"wpcf7-form-control-wrap text-4697\"><input type=\"text\" name=\"text-4697\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span><\/div><\/div>\n<div class='content-column one_half'><div style=\"padding-top:20px;\">Start date: <span class=\"wpcf7-form-control-wrap date-4254\"><input type=\"date\" name=\"date-4254\" value=\"\" class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date\" aria-invalid=\"false\" \/><\/span><\/div><\/div>\n<div class='content-column one_half last_column'><div style=\"padding-top:20px;\">Ending date: <span class=\"wpcf7-form-control-wrap date-4255\"><input type=\"date\" name=\"date-4255\" value=\"\" class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date\" aria-invalid=\"false\" \/><\/span><\/div><\/div><div class='clear_column'><\/div>\n<div class='content-column full_width'><div style=\"padding-top:20px;\">Comments: <span class=\"wpcf7-form-control-wrap textarea-4204\"><textarea name=\"textarea-4204\" cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\"><\/textarea><\/span><\/div><\/div>\n<div class='content-column full_width'><div style=\"padding-top:20px;\">Do you wish to add another disease? <span class=\"wpcf7-form-control-wrap radio-4370\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-4370\" value=\"S\u00ed\" \/><span class=\"wpcf7-list-item-label\">S\u00ed<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-4370\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span><\/div><\/div><\/div>\n<div id=\"grupo_enfermedades-previas-5\" data-clear_on_hide data-class=\"wpcf7cf_group\">\n<div class='content-column full_width'><div style=\"padding-top:20px;\"><p style=\"text-align: justify;\">Please, in case you have more diseases to add use this text field to list them adding in each case: Name of the disease, date of beginning and end of the disease and any other comments that you consider appropriate, thank you. &nbsp;<br \/>\n<span class=\"wpcf7-form-control-wrap textarea-5204\"><textarea name=\"textarea-5204\" cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\"><\/textarea><\/span><\/p><\/div><\/div><\/div>\n<div class='content-column full_width'><div style=\"padding-top:40px;\"><h3><strong>DATA OF ADVERSE REACTION (RAM)<\/strong><\/h3><\/div><\/div>\n<h3><strong>RAM:<\/strong><\/h3>\n<div class='content-column full_width'><div style=\"padding-top:20px;\">Enter here the RAM that you have experienced: <span class=\"wpcf7-form-control-wrap text-01860\"><input type=\"text\" name=\"text-01860\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span><\/div><\/div>\n<div class='content-column one_half'><div style=\"padding-top:20px;\">Start date: <span class=\"wpcf7-form-control-wrap date-1355\"><input type=\"date\" name=\"date-1355\" value=\"\" class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date\" aria-invalid=\"false\" \/><\/span><\/div><\/div>\n<div class='content-column one_half last_column'><div style=\"padding-top:20px;\">Ending date: <span class=\"wpcf7-form-control-wrap date-1356\"><input type=\"date\" name=\"date-1356\" value=\"\" class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date\" aria-invalid=\"false\" \/><\/span><\/div><\/div><div class='clear_column'><\/div>\n<div class='content-column one_third'><div style=\"padding-top:10px;padding-right:10px;\">Outcome:<br \/>\n<span class=\"wpcf7-form-control-wrap your-browser-desenlace\"><select name=\"your-browser-desenlace\" class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\"><option value=\"\">---<\/option><option value=\"Unknown\">Unknown<\/option><option value=\"Recovered\/Resolved\">Recovered\/Resolved<\/option><option value=\"In recovery\/In resolution\">In recovery\/In resolution<\/option><option value=\"Not recovered\/Not resolved\">Not recovered\/Not resolved<\/option><option value=\"Recovered\/Resolved with sequel\">Recovered\/Resolved with sequel<\/option><option value=\"Mortal\">Mortal<\/option><\/select><\/span><\/div><\/div>\n<div class='content-column one_third'><div style=\"padding-top:10px;padding-right:10px;padding-left:-40px;\">Gravity:<br \/>\n<span class=\"wpcf7-form-control-wrap your-browser-gravedad\"><select name=\"your-browser-gravedad\" class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\"><option value=\"\">---<\/option><option value=\"Not serious\">Not serious<\/option><option value=\"Serious\">Serious<\/option><\/select><\/span><\/div><\/div>\n<div class='content-column full_width'><div style=\"padding-top:10px;padding-right:10px;\">If you marked \"serious\", indicate us:<br \/>\n<span class=\"wpcf7-form-control-wrap your-browser-si-marco-grave\"><select name=\"your-browser-si-marco-grave\" class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\"><option value=\"\">---<\/option><option value=\"It has caused death\">It has caused death<\/option><option value=\"Has endangered life\">Has endangered life<\/option><option value=\"It has been the cause of patient hospitalization\">It has been the cause of patient hospitalization<\/option><option value=\"It has meant the extension of an existing hospitalization\">It has meant the extension of an existing hospitalization<\/option><option value=\"Has caused a significant or persistent disability or disability\">Has caused a significant or persistent disability or disability<\/option><option value=\"Has caused a congenital anomaly or birth defect\">Has caused a congenital anomaly or birth defect<\/option><option value=\"It has not caused any of the above but I think it is very important\">It has not caused any of the above but I think it is very important<\/option><\/select><\/span><\/div><\/div>\n<div class='content-column one_half last_column'><div style=\"padding-top:10px;padding-right:10px;\">Enter country where RAM has occurred: <span class=\"wpcf7-form-control-wrap text-3636\"><input type=\"text\" name=\"text-3636\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span><\/div><\/div><div class='clear_column'><\/div>\n<div class='content-column full_width'><div style=\"padding-top:20px;padding-right:10px;\">Have you informed your doctor of RAM? <span class=\"wpcf7-form-control-wrap radio-1999\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-1999\" value=\"S\u00ed\" \/><span class=\"wpcf7-list-item-label\">S\u00ed<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-1999\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span><\/div><\/div>\n<div class='content-column full_width'><div style=\"padding-top:10px;padding-right:10px;\">Do you give us permission to contact your doctor about this RAM? <span class=\"wpcf7-form-control-wrap radio-19910\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-19910\" value=\"S\u00ed\" \/><span class=\"wpcf7-list-item-label\">S\u00ed<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-19910\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span><\/div><\/div>\n<div class='content-column full_width'><div style=\"padding-top:12px;\">If yes, and you give us your permission, enter the following contact information please:<\/div><\/div>\n<div class='content-column one_third'><div style=\"padding-top:10px;padding-right:10px;\">Name: <span class=\"wpcf7-form-control-wrap text-3637\"><input type=\"text\" name=\"text-3637\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span><\/div><\/div>\n<div class='content-column one_third'><div style=\"padding-top:10px;padding-right:10px;\">Surnames: <span class=\"wpcf7-form-control-wrap text-3638\"><input type=\"text\" name=\"text-3638\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span><\/div><\/div>\n<div class='content-column one_third last_column'><div style=\"padding-top:10px;padding-right:10px;\">Address: <span class=\"wpcf7-form-control-wrap text-3639\"><input type=\"text\" name=\"text-3639\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span><\/div><\/div><div class='clear_column'><\/div>\n<div class='content-column one_half'><div style=\"padding-top:10px;padding-right:10px;\">Telephone contact: <span class=\"wpcf7-form-control-wrap tel-689\"><input type=\"tel\" name=\"tel-689\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-tel wpcf7-validates-as-tel\" aria-invalid=\"false\" \/><\/span><\/div><\/div>\n<div class='content-column one_half last_column'><div style=\"padding-top:10px;padding-right:10px;\">E-mail contact: <span class=\"wpcf7-form-control-wrap email-877\"><input type=\"email\" name=\"email-877\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-email wpcf7-validates-as-email\" aria-invalid=\"false\" \/><\/span><\/div><\/div><div class='clear_column'><\/div>\n<div class='content-column full_width'><div style=\"padding-top:30px;padding-right:10px;\">Is it a RAM related to a <strong>medication error<\/strong>? <span class=\"wpcf7-form-control-wrap radio-19911\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-19911\" value=\"S\u00ed\" \/><span class=\"wpcf7-list-item-label\">S\u00ed<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-19911\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span><\/div><\/div>\n<div class='content-column full_width'><div style=\"padding-top:20px;\"><p style=\"text-align: justify;\"><strong>*Medication error:<\/strong> It is an unintentional failure in the process of medication treatment that causes or may cause harm to the patient. It may be related to prescription, dispensing and \/ or administration.<\/p><\/div><\/div>\n<div class='content-column full_width'><div style=\"padding-top:-10px;\">Do you wish to add another RAM? <span class=\"wpcf7-form-control-wrap radio-1858\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-1858\" value=\"S\u00ed\" \/><span class=\"wpcf7-list-item-label\">S\u00ed<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-1858\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span><\/div><\/div>\n<div id=\"grupo_ram-2\" data-clear_on_hide data-class=\"wpcf7cf_group\">\n<div class='content-column full_width'><div style=\"padding-top:30px;\"><h3><strong>RAM n\u00ba2 :<\/strong><\/h3><\/div><\/div>\n<div class='content-column full_width'><div style=\"padding-top:20px;\">Enter here the RAM that you have experienced: <span class=\"wpcf7-form-control-wrap text-02860\"><input type=\"text\" name=\"text-02860\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span><\/div><\/div>\n<div class='content-column one_half'><div style=\"padding-top:20px;\">Start date: <span class=\"wpcf7-form-control-wrap date-221355\"><input type=\"date\" name=\"date-221355\" value=\"\" class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date\" aria-invalid=\"false\" \/><\/span><\/div><\/div>\n<div class='content-column one_half last_column'><div style=\"padding-top:20px;\">Ending date: <span class=\"wpcf7-form-control-wrap date-221356\"><input type=\"date\" name=\"date-221356\" value=\"\" class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date\" aria-invalid=\"false\" \/><\/span><\/div><\/div><div class='clear_column'><\/div>\n<div class='content-column one_third'><div style=\"padding-top:10px;padding-right:10px;\">Outcome:<br \/>\n<span class=\"wpcf7-form-control-wrap your-browser-desenlace-2\"><select name=\"your-browser-desenlace-2\" class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\"><option value=\"\">---<\/option><option value=\"Unknown\">Unknown<\/option><option value=\"Recovered\/Resolved\">Recovered\/Resolved<\/option><option value=\"In recovery\/In resolution\">In recovery\/In resolution<\/option><option value=\"Not recovered\/Not resolved\">Not recovered\/Not resolved<\/option><option value=\"Recovered\/Resolved with sequel\">Recovered\/Resolved with sequel<\/option><option value=\"Mortal\">Mortal<\/option><\/select><\/span><\/div><\/div>\n<div class='content-column one_third'><div style=\"padding-top:10px;padding-right:10px;padding-left:-40px;\">Gravity:<br \/>\n<span class=\"wpcf7-form-control-wrap your-browser-gravedad-2\"><select name=\"your-browser-gravedad-2\" class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\"><option value=\"\">---<\/option><option value=\"Not serious\">Not serious<\/option><option value=\"Serious\">Serious<\/option><\/select><\/span><\/div><\/div>\n<div class='content-column full_width'><div style=\"padding-top:10px;padding-right:10px;\">If you marked \"serious\", indicate us:<br \/>\n<span class=\"wpcf7-form-control-wrap your-browser-si-marco-grave-2\"><select name=\"your-browser-si-marco-grave-2\" class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\"><option value=\"\">---<\/option><option value=\"It has caused death\">It has caused death<\/option><option value=\"Has endangered life\">Has endangered life<\/option><option value=\"It has been the cause of patient hospitalization\">It has been the cause of patient hospitalization<\/option><option value=\"It has meant the extension of an existing hospitalization\">It has meant the extension of an existing hospitalization<\/option><option value=\"Has caused a significant or persistent disability or disability\">Has caused a significant or persistent disability or disability<\/option><option value=\"Has caused a congenital anomaly or birth defect\">Has caused a congenital anomaly or birth defect<\/option><option value=\"It has not caused any of the above but I think it is very important\">It has not caused any of the above but I think it is very important<\/option><\/select><\/span><\/div><\/div>\n<div class='content-column one_half last_column'><div style=\"padding-top:10px;padding-right:10px;\">Enter country where RAM has occurred: <span class=\"wpcf7-form-control-wrap text-223636\"><input type=\"text\" name=\"text-223636\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span><\/div><\/div><div class='clear_column'><\/div>\n<div class='content-column full_width'><div style=\"padding-top:20px;padding-right:10px;\">Have you informed your doctor of RAM? <span class=\"wpcf7-form-control-wrap radio-221999\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-221999\" value=\"S\u00ed\" \/><span class=\"wpcf7-list-item-label\">S\u00ed<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-221999\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span><\/div><\/div>\n<div class='content-column full_width'><div style=\"padding-top:10px;padding-right:10px;\">Do you give us permission to contact your doctor about this RAM? <span class=\"wpcf7-form-control-wrap radio-2219910\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-2219910\" value=\"S\u00ed\" \/><span class=\"wpcf7-list-item-label\">S\u00ed<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-2219910\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span><\/div><\/div>\n<div class='content-column full_width'><div style=\"padding-top:12px;\">If yes, and you give us your permission, enter the following contact information please:<\/div><\/div>\n<div class='content-column one_third'><div style=\"padding-top:10px;padding-right:10px;\">Name: <span class=\"wpcf7-form-control-wrap text-223637\"><input type=\"text\" name=\"text-223637\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span><\/div><\/div>\n<div class='content-column one_third'><div style=\"padding-top:10px;padding-right:10px;\">Surnames: <span class=\"wpcf7-form-control-wrap text-223638\"><input type=\"text\" name=\"text-223638\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span><\/div><\/div>\n<div class='content-column one_third last_column'><div style=\"padding-top:10px;padding-right:10px;\">Address: <span class=\"wpcf7-form-control-wrap text-223639\"><input type=\"text\" name=\"text-223639\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span><\/div><\/div><div class='clear_column'><\/div>\n<div class='content-column one_half'><div style=\"padding-top:10px;padding-right:10px;\">Telephone contact: <span class=\"wpcf7-form-control-wrap tel-22689\"><input type=\"tel\" name=\"tel-22689\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-tel wpcf7-validates-as-tel\" aria-invalid=\"false\" \/><\/span><\/div><\/div>\n<div class='content-column one_half last_column'><div style=\"padding-top:10px;padding-right:10px;\">E-mail contact: <span class=\"wpcf7-form-control-wrap email-22877\"><input type=\"email\" name=\"email-22877\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-email wpcf7-validates-as-email\" aria-invalid=\"false\" \/><\/span><\/div><\/div><div class='clear_column'><\/div>\n<div class='content-column full_width'><div style=\"padding-top:30px;padding-right:10px;\">Is it a RAM related to a <strong>medication error<\/strong>? <span class=\"wpcf7-form-control-wrap radio-2219911\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-2219911\" value=\"S\u00ed\" \/><span class=\"wpcf7-list-item-label\">S\u00ed<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-2219911\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span><\/div><\/div>\n<div class='content-column full_width'><div style=\"padding-top:20px;\"><p style=\"text-align: justify;\"><strong>*Medication error:<\/strong> It is an unintentional failure in the process of medication treatment that causes or may cause harm to the patient. It may be related to prescription, dispensing and \/ or administration.<\/p><\/div><\/div>\n<div class='content-column full_width'><div style=\"padding-top:-10px;\">Do you wish to add another RAM? <span class=\"wpcf7-form-control-wrap radio-221858\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-221858\" value=\"S\u00ed\" \/><span class=\"wpcf7-list-item-label\">S\u00ed<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-221858\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span><\/div><\/div><\/div>\n<div id=\"grupo_ram-3\" data-clear_on_hide data-class=\"wpcf7cf_group\">\n<div class='content-column full_width'><div style=\"padding-top:30px;\"><h3><strong>RAM n\u00ba3 :<\/strong><\/h3><\/div><\/div>\n<div class='content-column full_width'><div style=\"padding-top:20px;\">Enter here the RAM that you have experienced: <span class=\"wpcf7-form-control-wrap text-03860\"><input type=\"text\" name=\"text-03860\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span><\/div><\/div>\n<div class='content-column one_half'><div style=\"padding-top:20px;\">Start date: <span class=\"wpcf7-form-control-wrap date-331355\"><input type=\"date\" name=\"date-331355\" value=\"\" class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date\" aria-invalid=\"false\" \/><\/span><\/div><\/div>\n<div class='content-column one_half last_column'><div style=\"padding-top:20px;\">Ending date: <span class=\"wpcf7-form-control-wrap date-331356\"><input type=\"date\" name=\"date-331356\" value=\"\" class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date\" aria-invalid=\"false\" \/><\/span><\/div><\/div><div class='clear_column'><\/div>\n<div class='content-column one_third'><div style=\"padding-top:10px;padding-right:10px;\">Outcome:<br \/>\n<span class=\"wpcf7-form-control-wrap your-browser-desenlace-3\"><select name=\"your-browser-desenlace-3\" class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\"><option value=\"\">---<\/option><option value=\"Unknown\">Unknown<\/option><option value=\"Recovered\/Resolved\">Recovered\/Resolved<\/option><option value=\"In recovery\/In resolution\">In recovery\/In resolution<\/option><option value=\"Not recovered\/Not resolved\">Not recovered\/Not resolved<\/option><option value=\"Recovered\/Resolved with sequel\">Recovered\/Resolved with sequel<\/option><option value=\"Mortal\">Mortal<\/option><\/select><\/span><\/div><\/div>\n<div class='content-column one_third'><div style=\"padding-top:10px;padding-right:10px;padding-left:-40px;\">Gravity:<br \/>\n<span class=\"wpcf7-form-control-wrap your-browser-gravedad-3\"><select name=\"your-browser-gravedad-3\" class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\"><option value=\"\">---<\/option><option value=\"Not serious\">Not serious<\/option><option value=\"Serious\">Serious<\/option><\/select><\/span><\/div><\/div>\n<div class='content-column full_width'><div style=\"padding-top:10px;padding-right:10px;\">If you marked \"serious\", indicate us:<br \/>\n<span class=\"wpcf7-form-control-wrap your-browser-si-marco-grave-3\"><select name=\"your-browser-si-marco-grave-3\" class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\"><option value=\"\">---<\/option><option value=\"It has caused death\">It has caused death<\/option><option value=\"Has endangered life\">Has endangered life<\/option><option value=\"It has been the cause of patient hospitalization\">It has been the cause of patient hospitalization<\/option><option value=\"It has meant the extension of an existing hospitalization\">It has meant the extension of an existing hospitalization<\/option><option value=\"Has caused a significant or persistent disability or disability\">Has caused a significant or persistent disability or disability<\/option><option value=\"Has caused a congenital anomaly or birth defect\">Has caused a congenital anomaly or birth defect<\/option><option value=\"It has not caused any of the above but I think it is very important\">It has not caused any of the above but I think it is very important<\/option><\/select><\/span><\/div><\/div>\n<div class='content-column one_half last_column'><div style=\"padding-top:10px;padding-right:10px;\">Enter country where RAM has occurred: <span class=\"wpcf7-form-control-wrap text-333636\"><input type=\"text\" name=\"text-333636\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span><\/div><\/div><div class='clear_column'><\/div>\n<div class='content-column full_width'><div style=\"padding-top:20px;padding-right:10px;\">Have you informed your doctor of RAM? <span class=\"wpcf7-form-control-wrap radio-331999\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-331999\" value=\"S\u00ed\" \/><span class=\"wpcf7-list-item-label\">S\u00ed<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-331999\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span><\/div><\/div>\n<div class='content-column full_width'><div style=\"padding-top:10px;padding-right:10px;\">Do you give us permission to contact your doctor about this RAM? <span class=\"wpcf7-form-control-wrap radio-3319910\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-3319910\" value=\"S\u00ed\" \/><span class=\"wpcf7-list-item-label\">S\u00ed<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-3319910\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span><\/div><\/div>\n<div class='content-column full_width'><div style=\"padding-top:12px;\">If yes, and you give us your permission, enter the following contact information please:<\/div><\/div>\n<div class='content-column one_third'><div style=\"padding-top:10px;padding-right:10px;\">Name: <span class=\"wpcf7-form-control-wrap text-333637\"><input type=\"text\" name=\"text-333637\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span><\/div><\/div>\n<div class='content-column one_third'><div style=\"padding-top:10px;padding-right:10px;\">Surnames: <span class=\"wpcf7-form-control-wrap text-333638\"><input type=\"text\" name=\"text-333638\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span><\/div><\/div>\n<div class='content-column one_third last_column'><div style=\"padding-top:10px;padding-right:10px;\">Address: <span class=\"wpcf7-form-control-wrap text-333639\"><input type=\"text\" name=\"text-333639\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span><\/div><\/div><div class='clear_column'><\/div>\n<div class='content-column one_half'><div style=\"padding-top:10px;padding-right:10px;\">Telephone contact: <span class=\"wpcf7-form-control-wrap tel-33689\"><input type=\"tel\" name=\"tel-33689\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-tel wpcf7-validates-as-tel\" aria-invalid=\"false\" \/><\/span><\/div><\/div>\n<div class='content-column one_half last_column'><div style=\"padding-top:10px;padding-right:10px;\">E-mail contact: <span class=\"wpcf7-form-control-wrap email-33877\"><input type=\"email\" name=\"email-33877\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-email wpcf7-validates-as-email\" aria-invalid=\"false\" \/><\/span><\/div><\/div><div class='clear_column'><\/div>\n<div class='content-column full_width'><div style=\"padding-top:30px;padding-right:10px;\">Is it a RAM related to a <strong>medication error<\/strong>? <span class=\"wpcf7-form-control-wrap radio-3319911\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-3319911\" value=\"S\u00ed\" \/><span class=\"wpcf7-list-item-label\">S\u00ed<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-3319911\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span><\/div><\/div>\n<div class='content-column full_width'><div style=\"padding-top:20px;\"><p style=\"text-align: justify;\"><strong>*Medication error:<\/strong> It is an unintentional failure in the process of medication treatment that causes or may cause harm to the patient. It may be related to prescription, dispensing and \/ or administration.<\/p><\/div><\/div>\n<div class='content-column full_width'><div style=\"padding-top:-10px;\">Do you wish to add another RAM? <span class=\"wpcf7-form-control-wrap radio-331858\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-331858\" value=\"S\u00ed\" \/><span class=\"wpcf7-list-item-label\">S\u00ed<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-331858\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span><\/div><\/div><\/div>\n<div id=\"grupo_ram-4\" data-clear_on_hide data-class=\"wpcf7cf_group\">\n<div class='content-column full_width'><div style=\"padding-top:30px;\"><h3><strong>RAM n\u00ba4 :<\/strong><\/h3><\/div><\/div>\n<div class='content-column full_width'><div style=\"padding-top:20px;\">Enter here the RAM that you have experienced: <span class=\"wpcf7-form-control-wrap text-04860\"><input type=\"text\" name=\"text-04860\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span><\/div><\/div>\n<div class='content-column one_half'><div style=\"padding-top:20px;\">Start date: <span class=\"wpcf7-form-control-wrap date-441355\"><input type=\"date\" name=\"date-441355\" value=\"\" class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date\" aria-invalid=\"false\" \/><\/span><\/div><\/div>\n<div class='content-column one_half last_column'><div style=\"padding-top:20px;\">Ending date: <span class=\"wpcf7-form-control-wrap date-441356\"><input type=\"date\" name=\"date-441356\" value=\"\" class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date\" aria-invalid=\"false\" \/><\/span><\/div><\/div><div class='clear_column'><\/div>\n<div class='content-column one_third'><div style=\"padding-top:10px;padding-right:10px;\">Outcome:<br \/>\n<span class=\"wpcf7-form-control-wrap your-browser-desenlace-4\"><select name=\"your-browser-desenlace-4\" class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\"><option value=\"\">---<\/option><option value=\"Unknown\">Unknown<\/option><option value=\"Recovered\/Resolved\">Recovered\/Resolved<\/option><option value=\"In recovery\/In resolution\">In recovery\/In resolution<\/option><option value=\"Not recovered\/Not resolved\">Not recovered\/Not resolved<\/option><option value=\"Recovered\/Resolved with sequel\">Recovered\/Resolved with sequel<\/option><option value=\"Mortal\">Mortal<\/option><\/select><\/span><\/div><\/div>\n<div class='content-column one_third'><div style=\"padding-top:10px;padding-right:10px;padding-left:-40px;\">Gravity:<br \/>\n<span class=\"wpcf7-form-control-wrap your-browser-gravedad-4\"><select name=\"your-browser-gravedad-4\" class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\"><option value=\"\">---<\/option><option value=\"Not serious\">Not serious<\/option><option value=\"Serious\">Serious<\/option><\/select><\/span><\/div><\/div>\n<div class='content-column full_width'><div style=\"padding-top:10px;padding-right:10px;\">If you marked \"serious\", indicate us:<br \/>\n<span class=\"wpcf7-form-control-wrap your-browser-si-marco-grave-4\"><select name=\"your-browser-si-marco-grave-4\" class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\"><option value=\"\">---<\/option><option value=\"It has caused death\">It has caused death<\/option><option value=\"Has endangered life\">Has endangered life<\/option><option value=\"It has been the cause of patient hospitalization\">It has been the cause of patient hospitalization<\/option><option value=\"It has meant the extension of an existing hospitalization\">It has meant the extension of an existing hospitalization<\/option><option value=\"Has caused a significant or persistent disability or disability\">Has caused a significant or persistent disability or disability<\/option><option value=\"Has caused a congenital anomaly or birth defect\">Has caused a congenital anomaly or birth defect<\/option><option value=\"It has not caused any of the above but I think it is very important\">It has not caused any of the above but I think it is very important<\/option><\/select><\/span><\/div><\/div>\n<div class='content-column one_half last_column'><div style=\"padding-top:10px;padding-right:10px;\">Enter country where RAM has occurred: <span class=\"wpcf7-form-control-wrap text-443636\"><input type=\"text\" name=\"text-443636\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span><\/div><\/div><div class='clear_column'><\/div>\n<div class='content-column full_width'><div style=\"padding-top:20px;padding-right:10px;\">Have you informed your doctor of RAM? <span class=\"wpcf7-form-control-wrap radio-441999\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-441999\" value=\"S\u00ed\" \/><span class=\"wpcf7-list-item-label\">S\u00ed<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-441999\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span><\/div><\/div>\n<div class='content-column full_width'><div style=\"padding-top:10px;padding-right:10px;\">Do you give us permission to contact your doctor about this RAM? <span class=\"wpcf7-form-control-wrap radio-4419910\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-4419910\" value=\"S\u00ed\" \/><span class=\"wpcf7-list-item-label\">S\u00ed<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-4419910\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span><\/div><\/div>\n<div class='content-column full_width'><div style=\"padding-top:12px;\">If yes, and you give us your permission, enter the following contact information please:<\/div><\/div>\n<div class='content-column one_third'><div style=\"padding-top:10px;padding-right:10px;\">Name: <span class=\"wpcf7-form-control-wrap text-443637\"><input type=\"text\" name=\"text-443637\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span><\/div><\/div>\n<div class='content-column one_third'><div style=\"padding-top:10px;padding-right:10px;\">Surnames: <span class=\"wpcf7-form-control-wrap text-443638\"><input type=\"text\" name=\"text-443638\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span><\/div><\/div>\n<div class='content-column one_third last_column'><div style=\"padding-top:10px;padding-right:10px;\">Address: <span class=\"wpcf7-form-control-wrap text-443639\"><input type=\"text\" name=\"text-443639\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span><\/div><\/div><div class='clear_column'><\/div>\n<div class='content-column one_half'><div style=\"padding-top:10px;padding-right:10px;\">Telephone contact: <span class=\"wpcf7-form-control-wrap tel-44689\"><input type=\"tel\" name=\"tel-44689\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-tel wpcf7-validates-as-tel\" aria-invalid=\"false\" \/><\/span><\/div><\/div>\n<div class='content-column one_half last_column'><div style=\"padding-top:10px;padding-right:10px;\">E-mail contact: <span class=\"wpcf7-form-control-wrap email-44877\"><input type=\"email\" name=\"email-44877\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-email wpcf7-validates-as-email\" aria-invalid=\"false\" \/><\/span><\/div><\/div><div class='clear_column'><\/div>\n<div class='content-column full_width'><div style=\"padding-top:30px;padding-right:10px;\">Is it a RAM related to a <strong>medication error<\/strong>? <span class=\"wpcf7-form-control-wrap radio-4419911\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-4419911\" value=\"S\u00ed\" \/><span class=\"wpcf7-list-item-label\">S\u00ed<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-4419911\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span><\/div><\/div>\n<div class='content-column full_width'><div style=\"padding-top:20px;\"><p style=\"text-align: justify;\"><strong>*Medication error:<\/strong> It is an unintentional failure in the process of medication treatment that causes or may cause harm to the patient. It may be related to prescription, dispensing and \/ or administration.<\/p><\/div><\/div>\n<div class='content-column full_width'><div style=\"padding-top:-10px;\">Do you wish to add another RAM? <span class=\"wpcf7-form-control-wrap radio-441858\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-441858\" value=\"S\u00ed\" \/><span class=\"wpcf7-list-item-label\">S\u00ed<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-441858\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span><\/div><\/div><\/div>\n<div id=\"grupo_ram-5\" data-clear_on_hide data-class=\"wpcf7cf_group\">\n<div class='content-column full_width'><div style=\"padding-top:20px;\"><p style=\"text-align: justify;\">Please, in case you have more RAM to add, use this text field to list them, adding in each case the information provided in the previous RAM's and any other comments that you consider appropriate, thank you.&nbsp;<br \/>\n<span class=\"wpcf7-form-control-wrap textarea-8080\"><textarea name=\"textarea-8080\" cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\"><\/textarea><\/span><\/p><\/div><\/div><\/div>\n<div class='content-column full_width'><div style=\"padding-top:40px;\"><h3><strong>MEDICATION DATA<\/strong><\/h3><\/div><\/div>\n<h3><strong>Medication:<\/strong><\/h3>\n<div class='content-column full_width'><div style=\"\">Enter medication name: <span class=\"wpcf7-form-control-wrap text-656\"><input type=\"text\" name=\"text-656\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span><\/div><\/div>\n<div class='content-column one_half'><div style=\"padding-top:20px;\">Start date: <span class=\"wpcf7-form-control-wrap date-686\"><input type=\"date\" name=\"date-686\" value=\"\" class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date\" aria-invalid=\"false\" \/><\/span><\/div><\/div>\n<div class='content-column one_half last_column'><div style=\"padding-top:20px;\">Ending date: <span class=\"wpcf7-form-control-wrap date-687\"><input type=\"date\" name=\"date-687\" value=\"\" class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date\" aria-invalid=\"false\" \/><\/span><\/div><\/div><div class='clear_column'><\/div>\n<div class='content-column full_width'><div style=\"padding-top:20px;\">Role of the medicine*:<br \/>\n<span class=\"wpcf7-form-control-wrap your-browser-papel-medic\"><select name=\"your-browser-papel-medic\" class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\"><option value=\"\">---<\/option><option value=\"Suspect\">Suspect<\/option><option value=\"Concomitant*\">Concomitant*<\/option><\/select><\/span><\/div><\/div>\n<div class='content-column full_width'><div style=\"padding-top:30px;\"><p style=\"text-align: justify;\"><strong>*Concomitant:<\/strong> A drug that was used at the same time as the suspected drug but that you think is not related to RAM.<\/p><\/div><\/div>\n<div class='content-column one_third'><div style=\"padding-right:10px;\">Indication: <span class=\"wpcf7-form-control-wrap text-657\"><input type=\"text\" name=\"text-657\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span><\/div><\/div>\n<div class='content-column one_third'><div style=\"padding-right:10px;\">Dosage (posology): <span class=\"wpcf7-form-control-wrap text-658\"><input type=\"text\" name=\"text-658\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span><\/div><\/div>\n<div class='content-column one_third last_column'><div style=\"padding-right:10px;\">Lot: <span class=\"wpcf7-form-control-wrap text-659\"><input type=\"text\" name=\"text-659\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span><\/div><\/div><div class='clear_column'><\/div>\n<div class='content-column one_third'><div style=\"padding-top:10px;padding-right:10px;\">Pharmaceutical form: <span class=\"wpcf7-form-control-wrap text-660\"><input type=\"text\" name=\"text-660\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span><\/div><\/div>\n<div class='content-column one_third'><div style=\"padding-top:10px;padding-right:10px;\">Route of administration: <span class=\"wpcf7-form-control-wrap text-661\"><input type=\"text\" name=\"text-661\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span><\/div><\/div>\n<div class='content-column one_third last_column'><div style=\"padding-top:10px;padding-right:10px;\">Action taken with the medicine:<br \/>\n<span class=\"wpcf7-form-control-wrap your-browser-accion-medic\"><select name=\"your-browser-accion-medic\" class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\"><option value=\"\">---<\/option><option value=\"Unknown\">Unknown<\/option><option value=\"Withdrawal of the medication\">Withdrawal of the medication<\/option><option value=\"Dose reduction\">Dose reduction<\/option><option value=\"Increase in doses\">Increase in doses<\/option><option value=\"No change in dose\">No change in dose<\/option><\/select><\/span><\/div><\/div><div class='clear_column'><\/div>\n<div class='content-column full_width'><div style=\"padding-top:40px;\">Do you wish to add another medication? <span class=\"wpcf7-form-control-wrap radio-1178910\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-1178910\" value=\"S\u00ed\" \/><span class=\"wpcf7-list-item-label\">S\u00ed<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-1178910\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span><\/div><\/div>\n<div id=\"grupo_medicamento-2\" data-clear_on_hide data-class=\"wpcf7cf_group\">\n<div class='content-column full_width'><div style=\"padding-top:30px;\"><h3><strong>Medication n\u00ba2:<\/strong><\/h3><\/div><\/div>\n<div class='content-column full_width'><div style=\"\">Enter medication name: <span class=\"wpcf7-form-control-wrap text-22656\"><input type=\"text\" name=\"text-22656\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span><\/div><\/div>\n<div class='content-column one_half'><div style=\"padding-top:20px;\">Start date: <span class=\"wpcf7-form-control-wrap date-22686\"><input type=\"date\" name=\"date-22686\" value=\"\" class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date\" aria-invalid=\"false\" \/><\/span><\/div><\/div>\n<div class='content-column one_half last_column'><div style=\"padding-top:20px;\">Ending date: <span class=\"wpcf7-form-control-wrap date-22687\"><input type=\"date\" name=\"date-22687\" value=\"\" class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date\" aria-invalid=\"false\" \/><\/span><\/div><\/div><div class='clear_column'><\/div>\n<div class='content-column full_width'><div style=\"padding-top:20px;\">Role of the medicine*:<br \/>\n<span class=\"wpcf7-form-control-wrap your-browser-papel-medic-2\"><select name=\"your-browser-papel-medic-2\" class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\"><option value=\"\">---<\/option><option value=\"Suspect\">Suspect<\/option><option value=\"Concomitant*\">Concomitant*<\/option><\/select><\/span><\/div><\/div>\n<div class='content-column full_width'><div style=\"padding-top:30px;\"><p style=\"text-align: justify;\"><strong>*Concomitant:<\/strong> A drug that was used at the same time as the suspected drug but that you think is not related to RAM.<\/p><\/div><\/div>\n<div class='content-column one_third'><div style=\"padding-right:10px;\">Indication: <span class=\"wpcf7-form-control-wrap text-22657\"><input type=\"text\" name=\"text-22657\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span><\/div><\/div>\n<div class='content-column one_third'><div style=\"padding-right:10px;\">Dosage (posology): <span class=\"wpcf7-form-control-wrap text-22658\"><input type=\"text\" name=\"text-22658\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span><\/div><\/div>\n<div class='content-column one_third last_column'><div style=\"padding-right:10px;\">Lot: <span class=\"wpcf7-form-control-wrap text-22659\"><input type=\"text\" name=\"text-22659\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span><\/div><\/div><div class='clear_column'><\/div>\n<div class='content-column one_third'><div style=\"padding-top:10px;padding-right:10px;\">Pharmaceutical form: <span class=\"wpcf7-form-control-wrap text-22660\"><input type=\"text\" name=\"text-22660\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span><\/div><\/div>\n<div class='content-column one_third'><div style=\"padding-top:10px;padding-right:10px;\">Route of administration: <span class=\"wpcf7-form-control-wrap text-22661\"><input type=\"text\" name=\"text-22661\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span><\/div><\/div>\n<div class='content-column one_third last_column'><div style=\"padding-top:10px;padding-right:10px;\">Action taken with the medicine:<br \/>\n<span class=\"wpcf7-form-control-wrap your-browser-accion-medic-2\"><select name=\"your-browser-accion-medic-2\" class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\"><option value=\"\">---<\/option><option value=\"Unknown\">Unknown<\/option><option value=\"Withdrawal of the medication\">Withdrawal of the medication<\/option><option value=\"Dose reduction\">Dose reduction<\/option><option value=\"Increase in doses\">Increase in doses<\/option><option value=\"No change in dose\">No change in dose<\/option><\/select><\/span><\/div><\/div><div class='clear_column'><\/div>\n<div class='content-column full_width'><div style=\"padding-top:40px;\">Do you wish to add another medication? <span class=\"wpcf7-form-control-wrap radio-2278910\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-2278910\" value=\"S\u00ed\" \/><span class=\"wpcf7-list-item-label\">S\u00ed<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-2278910\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span><\/div><\/div>\n<\/div>\n<div id=\"grupo_medicamento-3\" data-clear_on_hide data-class=\"wpcf7cf_group\">\n<div class='content-column full_width'><div style=\"padding-top:30px;\"><h3><strong>Medication n\u00ba3:<\/strong><\/h3><\/div><\/div>\n<div class='content-column full_width'><div style=\"\">Enter medication name: <span class=\"wpcf7-form-control-wrap text-33656\"><input type=\"text\" name=\"text-33656\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span><\/div><\/div>\n<div class='content-column one_half'><div style=\"padding-top:20px;\">Start date: <span class=\"wpcf7-form-control-wrap date-33686\"><input type=\"date\" name=\"date-33686\" value=\"\" class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date\" aria-invalid=\"false\" \/><\/span><\/div><\/div>\n<div class='content-column one_half last_column'><div style=\"padding-top:20px;\">Ending date: <span class=\"wpcf7-form-control-wrap date-33687\"><input type=\"date\" name=\"date-33687\" value=\"\" class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date\" aria-invalid=\"false\" \/><\/span><\/div><\/div><div class='clear_column'><\/div>\n<div class='content-column full_width'><div style=\"padding-top:20px;\">Role of the medicine*:<br \/>\n<span class=\"wpcf7-form-control-wrap your-browser-papel-medic-3\"><select name=\"your-browser-papel-medic-3\" class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\"><option value=\"\">---<\/option><option value=\"Suspect\">Suspect<\/option><option value=\"Concomitant*\">Concomitant*<\/option><\/select><\/span><\/div><\/div>\n<div class='content-column full_width'><div style=\"padding-top:30px;\"><p style=\"text-align: justify;\"><strong>*Concomitant:<\/strong> A drug that was used at the same time as the suspected drug but that you think is not related to RAM.<\/p><\/div><\/div>\n<div class='content-column one_third'><div style=\"padding-right:10px;\">Indication: <span class=\"wpcf7-form-control-wrap text-33657\"><input type=\"text\" name=\"text-33657\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span><\/div><\/div>\n<div class='content-column one_third'><div style=\"padding-right:10px;\">Dosage (posology): <span class=\"wpcf7-form-control-wrap text-33658\"><input type=\"text\" name=\"text-33658\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span><\/div><\/div>\n<div class='content-column one_third last_column'><div style=\"padding-right:10px;\">Lot: <span class=\"wpcf7-form-control-wrap text-33659\"><input type=\"text\" name=\"text-33659\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span><\/div><\/div><div class='clear_column'><\/div>\n<div class='content-column one_third'><div style=\"padding-top:10px;padding-right:10px;\">Pharmaceutical form: <span class=\"wpcf7-form-control-wrap text-33660\"><input type=\"text\" name=\"text-33660\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span><\/div><\/div>\n<div class='content-column one_third'><div style=\"padding-top:10px;padding-right:10px;\">Route of administration: <span class=\"wpcf7-form-control-wrap text-33661\"><input type=\"text\" name=\"text-33661\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span><\/div><\/div>\n<div class='content-column one_third last_column'><div style=\"padding-top:10px;padding-right:10px;\">Action taken with the medicine:<br \/>\n<span class=\"wpcf7-form-control-wrap your-browser-accion-medic-3\"><select name=\"your-browser-accion-medic-3\" class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\"><option value=\"\">---<\/option><option value=\"Unknown\">Unknown<\/option><option value=\"Withdrawal of the medication\">Withdrawal of the medication<\/option><option value=\"Dose reduction\">Dose reduction<\/option><option value=\"Increase in doses\">Increase in doses<\/option><option value=\"No change in dose\">No change in dose<\/option><\/select><\/span><\/div><\/div><div class='clear_column'><\/div>\n<div class='content-column full_width'><div style=\"padding-top:40px;\">Do you wish to add another medication? <span class=\"wpcf7-form-control-wrap radio-3378910\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-3378910\" value=\"S\u00ed\" \/><span class=\"wpcf7-list-item-label\">S\u00ed<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-3378910\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span><\/div><\/div>\n<\/div>\n<div id=\"grupo_medicamento-4\" data-clear_on_hide data-class=\"wpcf7cf_group\">\n<div class='content-column full_width'><div style=\"padding-top:30px;\"><h3><strong>Medication n\u00ba4:<\/strong><\/h3><\/div><\/div>\n<div class='content-column full_width'><div style=\"\">Enter medication name: <span class=\"wpcf7-form-control-wrap text-44656\"><input type=\"text\" name=\"text-44656\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span><\/div><\/div>\n<div class='content-column one_half'><div style=\"padding-top:20px;\">Start date: <span class=\"wpcf7-form-control-wrap date-44686\"><input type=\"date\" name=\"date-44686\" value=\"\" class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date\" aria-invalid=\"false\" \/><\/span><\/div><\/div>\n<div class='content-column one_half last_column'><div style=\"padding-top:20px;\">Ending date: <span class=\"wpcf7-form-control-wrap date-44687\"><input type=\"date\" name=\"date-44687\" value=\"\" class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date\" aria-invalid=\"false\" \/><\/span><\/div><\/div><div class='clear_column'><\/div>\n<div class='content-column full_width'><div style=\"padding-top:20px;\">Role of the medicine*:<br \/>\n<span class=\"wpcf7-form-control-wrap your-browser-papel-medic-4\"><select name=\"your-browser-papel-medic-4\" class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\"><option value=\"\">---<\/option><option value=\"Suspect\">Suspect<\/option><option value=\"Concomitant*\">Concomitant*<\/option><\/select><\/span><\/div><\/div>\n<div class='content-column full_width'><div style=\"padding-top:30px;\"><p style=\"text-align: justify;\"><strong>*Concomitant:<\/strong> A drug that was used at the same time as the suspected drug but that you think is not related to RAM.<\/p><\/div><\/div>\n<div class='content-column one_third'><div style=\"padding-right:10px;\">Indication: <span class=\"wpcf7-form-control-wrap text-44657\"><input type=\"text\" name=\"text-44657\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span><\/div><\/div>\n<div class='content-column one_third'><div style=\"padding-right:10px;\">Dosage (posology): <span class=\"wpcf7-form-control-wrap text-44658\"><input type=\"text\" name=\"text-44658\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span><\/div><\/div>\n<div class='content-column one_third last_column'><div style=\"padding-right:10px;\">Lot: <span class=\"wpcf7-form-control-wrap text-44659\"><input type=\"text\" name=\"text-44659\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span><\/div><\/div><div class='clear_column'><\/div>\n<div class='content-column one_third'><div style=\"padding-top:10px;padding-right:10px;\">Pharmaceutical form: <span class=\"wpcf7-form-control-wrap text-44660\"><input type=\"text\" name=\"text-44660\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span><\/div><\/div>\n<div class='content-column one_third'><div style=\"padding-top:10px;padding-right:10px;\">Route of administration: <span class=\"wpcf7-form-control-wrap text-44661\"><input type=\"text\" name=\"text-44661\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span><\/div><\/div>\n<div class='content-column one_third last_column'><div style=\"padding-top:10px;padding-right:10px;\">Action taken with the medicine:<br \/>\n<span class=\"wpcf7-form-control-wrap your-browser-accion-medic-4\"><select name=\"your-browser-accion-medic-4\" class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\"><option value=\"\">---<\/option><option value=\"Unknown\">Unknown<\/option><option value=\"Withdrawal of the medication\">Withdrawal of the medication<\/option><option value=\"Dose reduction\">Dose reduction<\/option><option value=\"Increase in doses\">Increase in doses<\/option><option value=\"No change in dose\">No change in dose<\/option><\/select><\/span><\/div><\/div><div class='clear_column'><\/div>\n<div class='content-column full_width'><div style=\"padding-top:40px;\">Do you wish to add another medication? <span class=\"wpcf7-form-control-wrap radio-4478910\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-4478910\" value=\"S\u00ed\" \/><span class=\"wpcf7-list-item-label\">S\u00ed<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-4478910\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span><\/div><\/div>\n<\/div>\n<div id=\"grupo_medicamento-5\" data-clear_on_hide data-class=\"wpcf7cf_group\">\n<div class='content-column full_width'><div style=\"padding-top:20px;\"><p style=\"text-align: justify;\">Please, in case you have more medications to add, use this text field to list them, adding in each case: Name of the medication, start and end date, indicate if it is suspicious or concomitant, the indication, the batch, the dose , the pharmaceutical form, the route of administration and the action taken with the medicine, thank you.&nbsp;<br \/>\n<span class=\"wpcf7-form-control-wrap textarea-554236\"><textarea name=\"textarea-554236\" cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\"><\/textarea><\/span><\/p><\/div><\/div><\/div>\n<div class='content-column full_width'><div style=\"padding-top:40px;\"><h3><strong>NOTIFIER DATA<\/strong><\/h3><\/div><\/div>\n<div class='content-column one_third'><div style=\"padding-top:10px;padding-right:10px;\">Name*: <span class=\"wpcf7-form-control-wrap text-1234\"><input type=\"text\" name=\"text-1234\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span><\/div><\/div>\n<div class='content-column one_third'><div style=\"padding-top:10px;padding-right:10px;\">Surnames*: <span class=\"wpcf7-form-control-wrap text-1235\"><input type=\"text\" name=\"text-1235\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span><\/div><\/div>\n<div class='content-column one_third last_column'><div style=\"padding-top:10px;padding-right:10px;\">Organization\/Department*: <span class=\"wpcf7-form-control-wrap text-1236\"><input type=\"text\" name=\"text-1236\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span><\/div><\/div><div class='clear_column'><\/div>\n<div class='content-column one_half'><div style=\"padding-top:10px;padding-right:10px;\">Address (Street, Plaza, Avenue, ...): <span class=\"wpcf7-form-control-wrap text-1237\"><input type=\"text\" name=\"text-1237\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span><\/div><\/div>\n<div class='content-column one_half last_column'><div style=\"padding-top:10px;padding-right:10px;\">Number: <span class=\"wpcf7-form-control-wrap number-723\"><input type=\"number\" name=\"number-723\" value=\"\" class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-number\" aria-invalid=\"false\" \/><\/span><\/div><\/div><div class='clear_column'><\/div>\n<div class='content-column one_fourth'><div style=\"padding-top:10px;padding-right:10px;\">City*: <span class=\"wpcf7-form-control-wrap text-1238\"><input type=\"text\" name=\"text-1238\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span><\/div><\/div>\n<div class='content-column one_fourth'><div style=\"padding-top:10px;padding-right:10px;\">Postal Code*: <span class=\"wpcf7-form-control-wrap text-1239\"><input type=\"text\" name=\"text-1239\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span><\/div><\/div>\n<div class='content-column one_fourth'><div style=\"padding-top:10px;padding-right:10px;\">Province: <span class=\"wpcf7-form-control-wrap text-1240\"><input type=\"text\" name=\"text-1240\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span><\/div><\/div>\n<div class='content-column one_fourth last_column'><div style=\"padding-top:10px;padding-right:10px;\">Country: <span class=\"wpcf7-form-control-wrap text-1241\"><input type=\"text\" name=\"text-1241\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span><\/div><\/div><div class='clear_column'><\/div>\n<div class='content-column one_half'><div style=\"padding-top:10px;padding-right:10px;\">Telephone contact: <span class=\"wpcf7-form-control-wrap tel-75689\"><input type=\"tel\" name=\"tel-75689\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-tel wpcf7-validates-as-tel\" aria-invalid=\"false\" \/><\/span><\/div><\/div>\n<div class='content-column one_half last_column'><div style=\"padding-top:10px;padding-right:10px;\">E-mail contact*: <span class=\"wpcf7-form-control-wrap email-75877\"><input type=\"email\" name=\"email-75877\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-email wpcf7-validates-as-required wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span><\/div><\/div><div class='clear_column'><\/div>\n<div class='content-column full_width'><div style=\"padding-top:30px;\">Do you know if your doctor or pharmacist have notified the RAM to the authorities? <span class=\"wpcf7-form-control-wrap radio-112581\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-112581\" value=\"S\u00ed\" \/><span class=\"wpcf7-list-item-label\">S\u00ed<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-112581\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span><\/div><\/div>\n<div class='content-column five_sixth'><div style=\"padding-top:20px;\">If we need more information to understand the case, do you give us permission to contact you directly? <span class=\"wpcf7-form-control-wrap radio-112582\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-112582\" value=\"S\u00ed\" \/><span class=\"wpcf7-list-item-label\">S\u00ed<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-112582\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span><\/div><\/div>\n<div class='content-column full_width'><div style=\"padding-top:20px;\">Are you notifying additional information about a case that you had previously notified? <span class=\"wpcf7-form-control-wrap radio-112583\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"radio-112583\" value=\"S\u00ed\" \/><span class=\"wpcf7-list-item-label\">S\u00ed<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"radio-112583\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span><\/div><\/div>\n<div class='content-column full_width'><div style=\"padding-top:20px;\"><h6>*You must indicate at least City, P.C. and telephone or E-mail.<\/h6><\/div><\/div>\n<p><\/ br><br \/>\n<\/ br><br \/>\n<div class='content-column full_width'><div style=\"padding-top:40px;\"><span class=\"wpcf7-form-control-wrap acceptance-3232\"><input type=\"checkbox\" name=\"acceptance-3232\" value=\"1\" class=\"wpcf7-form-control wpcf7-acceptance\" aria-invalid=\"false\" \/><\/span>The information you provide will be managed according to our <a href=\"https:\/\/estedi.es\/ca\/politica-privacidad-reacciones-adversas\/\">Personal Data Protection Policy<\/a>. Confirm that you understand by checking the box.<\/div><\/div>\n<div class='content-column full_width'><div style=\"padding-top:40px;\"><div class=\"wpcf7-form-control-wrap\"><div data-sitekey=\"6LdPMUEUAAAAAFuDU2Gw9MhDMaxEMVV_R94ERuow\" class=\"wpcf7-form-control g-recaptcha wpcf7-recaptcha\"><\/div>\n<noscript>\n\t<div style=\"width: 302px; height: 422px;\">\n\t\t<div style=\"width: 302px; height: 422px; position: relative;\">\n\t\t\t<div style=\"width: 302px; height: 422px; position: absolute;\">\n\t\t\t\t<iframe src=\"https:\/\/www.google.com\/recaptcha\/api\/fallback?k=6LdPMUEUAAAAAFuDU2Gw9MhDMaxEMVV_R94ERuow\" frameborder=\"0\" scrolling=\"no\" style=\"width: 302px; height:422px; border-style: none;\">\n\t\t\t\t<\/iframe>\n\t\t\t<\/div>\n\t\t\t<div style=\"width: 300px; height: 60px; border-style: none; bottom: 12px; left: 25px; margin: 0px; padding: 0px; right: 25px; background: #f9f9f9; border: 1px solid #c1c1c1; border-radius: 3px;\">\n\t\t\t\t<textarea id=\"g-recaptcha-response\" name=\"g-recaptcha-response\" class=\"g-recaptcha-response\" style=\"width: 250px; height: 40px; border: 1px solid #c1c1c1; margin: 10px 25px; padding: 0px; resize: none;\">\n\t\t\t\t<\/textarea>\n\t\t\t<\/div>\n\t\t<\/div>\n\t<\/div>\n<\/noscript>\n<\/div>\n<p> &nbsp;<\/div><\/div><br \/>\n<div class='content-column full_width'><div style=\"padding-top:-10px;\"><input type=\"submit\" value=\"SUBMIT\" class=\"wpcf7-form-control wpcf7-submit\" \/><\/div><\/div>\n<div class=\"wpcf7-response-output wpcf7-display-none\"><\/div><\/form><\/div>[\/vc_column][\/vc_row]<\/p>\n<\/div>","protected":false},"excerpt":{"rendered":"<p>[vc_row full_width=&#8221;stretch_row&#8221;][vc_column][vc_column_text css_animation=&#8221;top-to-bottom&#8221;] If you (or someone known) has had a side effect to one of our medications, you can&#8230;<\/p>\n","protected":false},"author":1,"featured_media":317,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":[],"_links":{"self":[{"href":"https:\/\/estedi.es\/en\/wp-json\/wp\/v2\/pages\/679"}],"collection":[{"href":"https:\/\/estedi.es\/en\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/estedi.es\/en\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/estedi.es\/en\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/estedi.es\/en\/wp-json\/wp\/v2\/comments?post=679"}],"version-history":[{"count":16,"href":"https:\/\/estedi.es\/en\/wp-json\/wp\/v2\/pages\/679\/revisions"}],"predecessor-version":[{"id":713,"href":"https:\/\/estedi.es\/en\/wp-json\/wp\/v2\/pages\/679\/revisions\/713"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/estedi.es\/en\/wp-json\/wp\/v2\/media\/317"}],"wp:attachment":[{"href":"https:\/\/estedi.es\/en\/wp-json\/wp\/v2\/media?parent=679"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}