{"id":18529,"date":"2023-02-27T16:54:44","date_gmt":"2023-02-27T15:54:44","guid":{"rendered":"https:\/\/qualiphar.be\/?page_id=18529"},"modified":"2023-02-27T16:54:52","modified_gmt":"2023-02-27T15:54:52","slug":"notificacion-de-sospechas-de-reacciones-adversas-a-medicamentos","status":"publish","type":"page","link":"https:\/\/qualiphar.be\/es\/notificacion-de-sospechas-de-reacciones-adversas-a-medicamentos\/","title":{"rendered":"Notificaci\u00f3n de Sospechas de Reacciones Adversas a Medicamentos"},"content":{"rendered":"<p>[et_pb_section fb_built=\u00bb1&#8243; _builder_version=\u00bb4.16&#8243; custom_padding=\u00bb20px||||false|false\u00bb global_colors_info=\u00bb{}\u00bb][et_pb_row _builder_version=\u00bb4.16&#8243; global_colors_info=\u00bb{}\u00bb][et_pb_column type=\u00bb4_4&#8243; _builder_version=\u00bb4.16&#8243; global_colors_info=\u00bb{}\u00bb][et_pb_text admin_label=\u00bbtitel &#8211; Onze producten\u00bb _builder_version=\u00bb4.19.4&#8243; _dynamic_attributes=\u00bbcontent\u00bb global_colors_info=\u00bb{}\u00bb]@ET-DC@eyJkeW5hbWljIjp0cnVlLCJjb250ZW50IjoicG9zdF90aXRsZSIsInNldHRpbmdzIjp7ImJlZm9yZSI6IjxoMT4iLCJhZnRlciI6IjwvaDE+In19@[\/et_pb_text][et_pb_text _builder_version=\u00bb4.19.5&#8243; global_colors_info=\u00bb{}\u00bb]<\/p>\n<p>Todos los medicamentos tienen efectos secundarios y deben incluir un prospecto. Se entiende por efecto secundario un efecto no deseado o m\u00e9dico en un paciente que recibe tratamiento con un medicamento o preparado m\u00e9dico, que no est\u00e1 necesariamente relacionado con dicho tratamiento. Los efectos secundarios m\u00e1s frecuentes ya se conocen gracias a los estudios cl\u00ednicos. Algunos efectos secundarios s\u00f3lo se detectan cuando los toman muchas personas distintas. Tambi\u00e9n es posible que los efectos secundarios s\u00f3lo se produzcan tras un uso prolongado del medicamento y a veces los efectos secundarios se producen porque un medicamento se utiliza en combinaci\u00f3n con otros.<\/p>\n<p>Los complementos alimenticios entran dentro de la legislaci\u00f3n alimentaria porque legalmente son alimentos. Los prospectos de los complementos alimenticios no son obligatorios. Sin embargo, tambi\u00e9n pueden producirse reacciones no deseadas.<\/p>\n<p>[\/et_pb_text][\/et_pb_column][\/et_pb_row][et_pb_row use_custom_gutter=\u00bbon\u00bb gutter_width=\u00bb2&#8243; _builder_version=\u00bb4.19.4&#8243; custom_padding=\u00bb0px||||false|false\u00bb global_colors_info=\u00bb{}\u00bb][et_pb_column type=\u00bb4_4&#8243; _builder_version=\u00bb4.16&#8243; global_colors_info=\u00bb{}\u00bb][et_pb_text admin_label=\u00bbsubtitel\u00bb _builder_version=\u00bb4.19.5&#8243; text_font=\u00bbRubrik SemiBold|100|||||||\u00bb text_font_size=\u00bb26px\u00bb text_line_height=\u00bb1.72em\u00bb header_3_line_height=\u00bb1.2em\u00bb custom_padding=\u00bb|50px|||false|false\u00bb text_font_size_phone=\u00bb20px\u00bb text_font_size_last_edited=\u00bboff|tablet\u00bb header_3_font_size_tablet=\u00bb\u00bb header_3_font_size_phone=\u00bb20px\u00bb header_3_font_size_last_edited=\u00bbon|phone\u00bb global_colors_info=\u00bb{}\u00bb]<\/p>\n<h3>La importancia de notificar de sospechas de reacciones adversas a medicamentos<\/h3>\n<p>[\/et_pb_text][et_pb_text _builder_version=\u00bb4.19.5&#8243; custom_margin=\u00bb||40px||false|false\u00bb global_colors_info=\u00bb{}\u00bb]<\/p>\n<p>Qualiphar supervisa la seguridad de los medicamentos recogiendo e investigando todos los informes espont\u00e1neos de pacientes o profesionales sanitarios. Tambi\u00e9n tenemos la obligaci\u00f3n legal de recopilar todos los datos de forma an\u00f3nima en una base de datos internacional. En esta base de datos internacional, todos los pa\u00edses recogen informaci\u00f3n sobre los efectos secundarios de los medicamentos. Como empresa farmac\u00e9utica,<a href=\"https:\/\/www.famhp.be\/en\/reporting_a_side_effect_as_a_patient\" target=\"_blank\" rel=\"noopener\"> la Agencia Federal de Medicamentos y Productos Sanitarios (FAGG)<\/a> nos somete regularmente a auditor\u00edas. Por lo tanto, es importante que notifique su efecto secundario siempre.<\/p>\n<p>[\/et_pb_text][et_pb_text admin_label=\u00bbsubtitel\u00bb _builder_version=\u00bb4.19.5&#8243; text_font=\u00bbRubrik SemiBold|100|||||||\u00bb text_font_size=\u00bb26px\u00bb text_line_height=\u00bb1.72em\u00bb header_3_line_height=\u00bb1.2em\u00bb header_3_font_size_tablet=\u00bb\u00bb header_3_font_size_phone=\u00bb20px\u00bb header_3_font_size_last_edited=\u00bbon|phone\u00bb global_colors_info=\u00bb{}\u00bb]<\/p>\n<h3>\u00bfC\u00f3mo notificar?<\/h3>\n<p>[\/et_pb_text][et_pb_text admin_label=\u00bbTekst\u00bb _builder_version=\u00bb4.19.5&#8243; custom_margin=\u00bb||40px||false|false\u00bb global_colors_info=\u00bb{}\u00bb]<\/p>\n<p>Para ayudarnos a procesar su informaci\u00f3n de forma r\u00e1pida y eficaz, le rogamos que nos env\u00ede toda la informaci\u00f3n relevante que le sea posible utilizando el <a href=\"#contactform\">siguiente formulario<\/a>. Deber\u00e1 facilitar al menos la siguiente informaci\u00f3n:<\/p>\n<ul>\n<li>La informaci\u00f3n de contacto del informador, es decir, de la persona que realiza la notificaci\u00f3n.<\/li>\n<li>Las iniciales de la persona que experiment\u00f3 el posible efecto secundario y\/u otros datos personales, como sexo, fecha de nacimiento.<\/li>\n<li>El nombre del medicamento o producto de Qualiphar<\/li>\n<li>Una descripci\u00f3n del posible efecto secundario, como los s\u00edntomas experimentados, la fecha en que se produjo por primera vez y el resultado del posible efecto secundario.<\/li>\n<\/ul>\n<p>[\/et_pb_text][et_pb_text admin_label=\u00bbsubtitel\u00bb _builder_version=\u00bb4.19.5&#8243; text_font=\u00bbRubrik SemiBold|100|||||||\u00bb text_font_size=\u00bb26px\u00bb text_line_height=\u00bb1.72em\u00bb header_3_line_height=\u00bb1.2em\u00bb header_3_font_size_tablet=\u00bb\u00bb header_3_font_size_phone=\u00bb20px\u00bb header_3_font_size_last_edited=\u00bbon|phone\u00bb global_colors_info=\u00bb{}\u00bb]<\/p>\n<h3>\u00bfQu\u00e9 ocurre con su notificaci\u00f3n?<\/h3>\n<p>[\/et_pb_text][et_pb_text _builder_version=\u00bb4.19.5&#8243; custom_margin=\u00bb||40px||false|false\u00bb global_colors_info=\u00bb{}\u00bb]<\/p>\n<ol>\n<li>Nuestros colegas del departamento de Farmacovigilancia recogen, registran y analizan cada informe individual.<\/li>\n<li>Cuando se notifica un efecto secundario, Qualiphar podr\u00eda recopilar cierta informaci\u00f3n personal. Encontrar\u00e1 m\u00e1s informaci\u00f3n al respecto en la pol\u00edtica de privacidad.<\/li>\n<li>Cada efecto secundario se carga en la base de datos internacional y tambi\u00e9n es revisado all\u00ed por las autoridades. Los expertos eval\u00faan esos efectos secundarios para poder actuar en caso necesario, por ejemplo ajustando el prospecto o alertando a los profesionales sanitarios.<\/li>\n<\/ol>\n<p>Si tiene alguna pregunta sobre los efectos secundarios de los productos Qualiphar, puede ponerse en contacto directamente con Qualiphar. Tambi\u00e9n puede notificar los efectos secundarios directamente a la Agencia Federal de Medicamentos y Productos Sanitarios (FAMHP) visitando <a href=\"http:\/\/www.eenbijwerkingmelden.be\" target=\"_blank\" rel=\"noopener\">www.eenbijwerkingmelden.be<\/a>.<\/p>\n<p>[\/et_pb_text][\/et_pb_column][\/et_pb_row][et_pb_row disabled_on=\u00bboff|off|off\u00bb module_id=\u00bbcontactform\u00bb _builder_version=\u00bb4.19.5&#8243; _module_preset=\u00bbdefault\u00bb background_color=\u00bb#efefef\u00bb custom_padding=\u00bb|75px||75px|false|true\u00bb global_colors_info=\u00bb{}\u00bb][et_pb_column type=\u00bb4_4&#8243; _builder_version=\u00bb4.19.4&#8243; _module_preset=\u00bbdefault\u00bb global_colors_info=\u00bb{}\u00bb][de_fb_form title=\u00bbNotifique de sospechas de reacciones adversas a medicamentos\u00bb submit_button_text=\u00bbEnviar\u00bb scrollto_form_after_submit=\u00bboff\u00bb redirect_after_success=\u00bbon\u00bb redirect_url_after_submission=\u00bb@ET-DC@eyJkeW5hbWljIjp0cnVlLCJjb250ZW50IjoicG9zdF9saW5rX3VybF9wYWdlIiwic2V0dGluZ3MiOnsicG9zdF9pZCI6IjE3OTgyIn19@\u00bb failed_message=\u00bbRellene correctamente el formulario%%message%%\u00bb use_custom_email=\u00bboff\u00bb custom_contact_email=\u00bbpharmacovigilance@qualiphar.com\u00bb from_name=\u00bbcustom\u00bb custom_from_name=\u00bbPharmacovigilance Qualiphar\u00bb from_email=\u00bbcustom\u00bb custom_from_email=\u00bbpharmacovigilance@qualiphar.com\u00bb send_copy_to_sender=\u00bbon\u00bb sender_email_field=\u00bb4&#8243; reply_from_name=\u00bbcustom\u00bb reply_custom_from_name=\u00bbPharmacovigilance Qualiphar\u00bb reply_from_email=\u00bbcustom\u00bb reply_custom_from_email=\u00bbpharmacovigilance@qualiphar.com\u00bb reply_to_name=\u00bbPharmacovigilance Qualiphar\u00bb reply_to_email=\u00bbpharmacovigilance@qualiphar.com\u00bb reply_email_title=\u00bbMelding bijwerking Qualiphar product\u00bb radio_checkbox_checked_color=\u00bb#000000&#8243; multistep_enabled=\u00bbon\u00bb multistep_form_transition=\u00bbnone\u00bb multistep_progress_bar_style=\u00bblollipop\u00bb multistep_progress_bar_inactive_color=\u00bb#FFFFFF\u00bb multistep_show_progress_bar_percentage=\u00bbon\u00bb use_honeypot_captcha=\u00bboff\u00bb _builder_version=\u00bb4.19.5&#8243; _dynamic_attributes=\u00bbredirect_url_after_submission\u00bb _module_preset=\u00bbdefault\u00bb form_field_background_color=\u00bb#FFFFFF\u00bb form_field_text_color=\u00bb#000000&#8243; label_text_text_color=\u00bb#000000&#8243; custom_button=\u00bbon\u00bb button_text_color=\u00bb#FFFFFF\u00bb button_bg_color=\u00bb#00574a\u00bb button_border_color=\u00bbRGBA(255,255,255,0)\u00bb button_border_radius=\u00bb5px\u00bb custom_previous_step_button=\u00bbon\u00bb previous_step_button_text_color=\u00bb#FFFFFF\u00bb previous_step_button_bg_color=\u00bb#53af32&#8243; previous_step_button_border_color=\u00bbRGBA(255,255,255,0)\u00bb previous_step_button_border_radius=\u00bb5px\u00bb previous_step_button_icon=\u00bb&#x44;||divi||400&#8243; previous_step_button_icon_color=\u00bb#FFFFFF\u00bb previous_step_button_icon_placement=\u00bbleft\u00bb previous_step_button_on_hover=\u00bboff\u00bb custom_next_step_button=\u00bbon\u00bb next_step_button_text_color=\u00bb#FFFFFF\u00bb next_step_button_bg_color=\u00bb#53af32&#8243; next_step_button_border_color=\u00bbRGBA(255,255,255,0)\u00bb next_step_button_border_radius=\u00bb5px\u00bb next_step_button_icon=\u00bb&#x45;||divi||400&#8243; next_step_button_icon_color=\u00bb#FFFFFF\u00bb next_step_button_on_hover=\u00bboff\u00bb hover_enabled=\u00bb0&#8243; global_colors_info=\u00bb{}\u00bb sticky_enabled=\u00bb0&#8243;]<div class=\"et_pb_module de_fb_form_field de_fb_form_field_0 clearfix  grid_et_pb_column_4_4_12 et_pb_column_4_4 et_pb_column dfb_content_text_field\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t\t\t<div id=\"de_fb_melder_fk_0_wrapper\" class=\"field_wrapper search_filter_cont \" data-count=\"100\" >\r\n\t\t<\/p>\n<h3>Contactgegevens melder<\/h3>\n<p>\t\t<\/div>\r\n\n\t\t\t\t<\/div>\n\t\t\t<\/div><div class=\"et_pb_module de_fb_form_field de_fb_form_field_1 clearfix  grid_et_pb_column_2_3_12 et_pb_column_2_3 et_pb_column\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t\t\t<div id=\"de_fb_1_fk_1_wrapper\" class=\"field_wrapper search_filter_cont \" data-count=\"60\" >\r\n\t\t\t\t\t<label for=\"de_fb_1_fk_1\" class=\"field_label\">1. Voornaam <span class=\"de_fb_required\">*<\/span><\/label>\r\n\t\t\t\t\t\t\t\t\t<p class=\"et_pb_contact_field\" data-type=\"input\">\r\n\t\t\t<input type=\"hidden\" name=\"field_title[]\" value=\"1. Voornaam\"\/><input type=\"hidden\" name=\"field_name[]\" value=\"de_fb_1\"\/><input type=\"hidden\" name=\"field_id[]\" value=\"de_fb_1\"\/>\t\t\t\t\t\t\t<input type=\"text\" name=\"de_fb_1\" id=\"de_fb_1_fk_1\" data-calc_default=\"0\" placeholder=\"Voer uw antwoord in\"   class=\"divi-form-builder-field input-field \" required value=\"\"  data-msg-required=\"Verplicht invullen aub\" data-required_position=\"bottom\" autocomplete=\"on\" \/>\r\n\t\t\t\t\t\t\t\t\t<\/p>\r\n\r\n\t\t\t\t\t<\/div>\r\n\n\t\t\t\t<\/div>\n\t\t\t<\/div><div class=\"et_pb_module de_fb_form_field de_fb_form_field_2 clearfix  grid_et_pb_column_2_3_12 et_pb_column_2_3 et_pb_column\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t\t\t<div id=\"de_fb_2_2_fk_2_wrapper\" class=\"field_wrapper search_filter_cont \" data-count=\"60\" >\r\n\t\t\t\t\t<label for=\"de_fb_2_2_fk_2\" class=\"field_label\">2. Apellido  <span class=\"de_fb_required\">*<\/span><\/label>\r\n\t\t\t\t\t\t\t\t\t<p class=\"et_pb_contact_field\" data-type=\"input\">\r\n\t\t\t<input type=\"hidden\" name=\"field_title[]\" value=\"2. Apellido \"\/><input type=\"hidden\" name=\"field_name[]\" value=\"de_fb_2_2\"\/><input type=\"hidden\" name=\"field_id[]\" value=\"de_fb_2_2\"\/>\t\t\t\t\t\t\t<input type=\"text\" name=\"de_fb_2_2\" id=\"de_fb_2_2_fk_2\" data-calc_default=\"0\" placeholder=\"Introduzca su respuesta\"   class=\"divi-form-builder-field input-field \" required value=\"\"  data-msg-required=\"Introduzca su respuesta\" data-required_position=\"bottom\" autocomplete=\"on\" \/>\r\n\t\t\t\t\t\t\t\t\t<\/p>\r\n\r\n\t\t\t\t\t<\/div>\r\n\n\t\t\t\t<\/div>\n\t\t\t<\/div><div class=\"et_pb_module de_fb_form_field de_fb_form_field_3 clearfix  grid_et_pb_column_2_3_12 et_pb_column_2_3 et_pb_column\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t\t\t<div id=\"de_fb_3_2_fk_3_wrapper\" class=\"field_wrapper search_filter_cont \" data-count=\"60\" >\r\n\t\t\t\t\t<label for=\"de_fb_3_2_fk_3\" class=\"field_label\">3. T\u00e9l\u00e9phone <span class=\"de_fb_required\"><\/span><\/label>\r\n\t\t\t\t\t\t\t\t\t<p class=\"et_pb_contact_field\" data-type=\"input\">\r\n\t\t\t<input type=\"hidden\" name=\"field_title[]\" value=\"3. T\u00e9l\u00e9phone\"\/><input type=\"hidden\" name=\"field_name[]\" value=\"de_fb_3_2\"\/><input type=\"hidden\" name=\"field_id[]\" value=\"de_fb_3_2\"\/>\t\t\t\t\t\t\t<input type=\"text\" name=\"de_fb_3_2\" id=\"de_fb_3_2_fk_3\" data-calc_default=\"0\" placeholder=\"Saisissez votre r\u00e9ponse\"  pattern=\"[0-9\\s]*\"  class=\"divi-form-builder-field input-field \"  value=\"\"  data-msg-pattern=\"Invalid Format.\" autocomplete=\"on\" \/>\r\n\t\t\t\t\t\t\t\t\t<\/p>\r\n\r\n\t\t\t\t\t<\/div>\r\n\n\t\t\t\t<\/div>\n\t\t\t<\/div><div class=\"et_pb_module de_fb_form_field de_fb_form_field_4 clearfix  grid_et_pb_column_2_3_12 et_pb_column_2_3 et_pb_column\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t\t\t<div id=\"de_fb_4_fk_4_wrapper\" class=\"field_wrapper search_filter_cont \" data-count=\"60\" >\r\n\t\t\t\t\t<label for=\"de_fb_4_fk_4\" class=\"field_label\">1. Voornaam <span class=\"de_fb_required\">*<\/span><\/label>\r\n\t\t\t\t\t\t\t\t\t<p class=\"et_pb_contact_field\" data-type=\"input\">\r\n\t\t\t<input type=\"hidden\" name=\"field_title[]\" value=\"1. Voornaam\"\/><input type=\"hidden\" name=\"field_name[]\" value=\"de_fb_4\"\/><input type=\"hidden\" name=\"field_id[]\" value=\"de_fb_4\"\/>\t\t\t\t\t\t\t<input type=\"text\" name=\"de_fb_4\" id=\"de_fb_4_fk_4\" data-calc_default=\"0\" placeholder=\"Voer uw antwoord in\"   class=\"divi-form-builder-field input-field \" required value=\"\"  data-msg-required=\"Verplicht invullen aub\" data-required_position=\"bottom\" autocomplete=\"on\" \/>\r\n\t\t\t\t\t\t\t\t\t<\/p>\r\n\r\n\t\t\t\t\t<\/div>\r\n\n\t\t\t\t<\/div>\n\t\t\t<\/div><div class=\"et_pb_module de_fb_form_field de_fb_form_field_5 dfb_radio_default clearfix  grid_et_pb_column_2_3_12 et_pb_column_2_3 et_pb_column\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t\t\t<div id=\"de_fb_5_fk_5_wrapper\" class=\"field_wrapper search_filter_cont \" data-count=\"60\" >\r\n\t\t\t\t\t<label for=\"de_fb_5_fk_5\" class=\"field_label\">1. Voornaam <span class=\"de_fb_required\">*<\/span><\/label>\r\n\t\t\t\t\t\t\t\t\t<p class=\"et_pb_contact_field\" data-type=\"radio\">\r\n\t\t\t<input type=\"hidden\" name=\"field_title[]\" value=\"1. Voornaam\"\/><input type=\"hidden\" name=\"field_name[]\" value=\"de_fb_5\"\/><input type=\"hidden\" name=\"field_id[]\" value=\"de_fb_5\"\/><span class=\"et_pb_contact_field_options_wrapper\">\r\n\t\t\t\t\t\t\t\t<span class=\"et_pb_contact_field_options_list required\"  data-required_message=\"Verplicht invullen aub\" data-required_position=\"bottom\"><span class=\"et_pb_contact_field_checkbox\">\r\n\t\t\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_de_fb_5_fk_5_5_0\" class=\"divi-form-builder-field radio-field\" name=\"de_fb_5\" value=\"Paciente\" data-id=\"Paciente\" data-msg-required=\"Verplicht invullen aub\" data-required_position=\"bottom\">\r\n\t\t\t\t\t\t\t\t\t\t<label class=\"\" for=\"et_pb_contact_de_fb_5_fk_5_5_0\">\r\n\t\t\t\t\t\t\t\t\t\t\t<i><\/i>\r\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"label_wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t\t\t<span>Pati\u00ebnt<\/span>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t\t\t\t\t<\/span><span class=\"et_pb_contact_field_checkbox\">\r\n\t\t\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_de_fb_5_fk_5_5_1\" class=\"divi-form-builder-field radio-field\" name=\"de_fb_5\" value=\"M\u00e9dico de cabecera\" data-id=\"M\u00e9dico de cabecera\">\r\n\t\t\t\t\t\t\t\t\t\t<label class=\"\" for=\"et_pb_contact_de_fb_5_fk_5_5_1\">\r\n\t\t\t\t\t\t\t\t\t\t\t<i><\/i>\r\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"label_wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t\t\t<span>Huisarts<\/span>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t\t\t\t\t<\/span><span class=\"et_pb_contact_field_checkbox\">\r\n\t\t\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_de_fb_5_fk_5_5_2\" class=\"divi-form-builder-field radio-field\" name=\"de_fb_5\" value=\"Especialista\" data-id=\"Especialista\">\r\n\t\t\t\t\t\t\t\t\t\t<label class=\"\" for=\"et_pb_contact_de_fb_5_fk_5_5_2\">\r\n\t\t\t\t\t\t\t\t\t\t\t<i><\/i>\r\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"label_wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t\t\t<span>Specialist<\/span>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t\t\t\t\t<\/span><span class=\"et_pb_contact_field_checkbox\">\r\n\t\t\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_de_fb_5_fk_5_5_3\" class=\"divi-form-builder-field radio-field\" name=\"de_fb_5\" value=\"Farmac\u00e9utico\/a\" data-id=\"Farmac\u00e9utico\/a\">\r\n\t\t\t\t\t\t\t\t\t\t<label class=\"\" for=\"et_pb_contact_de_fb_5_fk_5_5_3\">\r\n\t\t\t\t\t\t\t\t\t\t\t<i><\/i>\r\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"label_wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t\t\t<span>Apotheker<\/span>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t\t\t\t\t<\/span><span class=\"et_pb_contact_field_checkbox\">\r\n\t\t\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_de_fb_5_fk_5_5_4\" class=\"divi-form-builder-field radio-field\" name=\"de_fb_5\" value=\"Enfermero\/a\" data-id=\"Enfermero\/a\">\r\n\t\t\t\t\t\t\t\t\t\t<label class=\"\" for=\"et_pb_contact_de_fb_5_fk_5_5_4\">\r\n\t\t\t\t\t\t\t\t\t\t\t<i><\/i>\r\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"label_wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t\t\t<span>Verpleger<\/span>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t\t\t\t\t<\/span><span class=\"et_pb_contact_field_checkbox\">\r\n\t\t\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_de_fb_5_fk_5_5_5\" class=\"divi-form-builder-field radio-field\" name=\"de_fb_5\" value=\"Otro\" data-id=\"Otro\">\r\n\t\t\t\t\t\t\t\t\t\t<label class=\"\" for=\"et_pb_contact_de_fb_5_fk_5_5_5\">\r\n\t\t\t\t\t\t\t\t\t\t\t<i><\/i>\r\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"label_wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t\t\t<span>Andere<\/span>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t\t\t\t\t<\/span><\/span>\r\n\t\t\t\t\t\t\t<\/span>\t\t\t<\/p>\r\n\r\n\t\t\t\t\t<\/div>\r\n\n\t\t\t\t<\/div>\n\t\t\t<\/div><div class=\"et_pb_module de_fb_form_field de_fb_form_field_6 clearfix  grid_et_pb_column_2_3_12 et_pb_column_2_3 et_pb_column\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t\t\t<div id=\"de_fb_5-andere_fk_6_wrapper\" class=\"field_wrapper search_filter_cont \" data-count=\"60\" >\r\n\t\t\t\t\t\t\t\t<p class=\"et_pb_contact_field\" data-type=\"input\">\r\n\t\t\t<input type=\"hidden\" name=\"field_title[]\" value=\"5-Andere\"\/><input type=\"hidden\" name=\"field_name[]\" value=\"de_fb_5-andere\"\/><input type=\"hidden\" name=\"field_id[]\" value=\"de_fb_5-andere\"\/>\t\t\t\t\t\t\t<input type=\"text\" name=\"de_fb_5-andere\" id=\"de_fb_5-andere_fk_6\" data-calc_default=\"0\" placeholder=\"Geben Sie bitte Ihre Antwort ein\"   class=\"divi-form-builder-field input-field \"  value=\"\"  autocomplete=\"on\" \/>\r\n\t\t\t\t\t\t\t\t\t<\/p>\r\n\r\n\t\t\t\t\t<\/div>\r\n\n\t\t\t\t<\/div>\n\t\t\t<\/div><div class=\"et_pb_module de_fb_form_field de_fb_form_field_7 clearfix  empty_module\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t\n\t\t\t\t<\/div>\n\t\t\t<\/div><div class=\"et_pb_module de_fb_form_field de_fb_form_field_8 clearfix  grid_et_pb_column_4_4_12 et_pb_column_4_4 et_pb_column dfb_content_text_field\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t\t\t<div id=\"de_fb_pati\u00ebnt_fk_8_wrapper\" class=\"field_wrapper search_filter_cont \" data-count=\"100\" >\r\n\t\t<\/p>\n<h3>Datos del paciente<\/h3>\n<p>\t\t<\/div>\r\n\n\t\t\t\t<\/div>\n\t\t\t<\/div><div class=\"et_pb_module de_fb_form_field de_fb_form_field_9 clearfix  grid_et_pb_column_2_3_12 et_pb_column_2_3 et_pb_column\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t\t\t<div id=\"de_fb_6_fk_9_wrapper\" class=\"field_wrapper search_filter_cont \" data-count=\"60\" >\r\n\t\t\t\t\t<label for=\"de_fb_6_fk_9\" class=\"field_label\">1. Voornaam <span class=\"de_fb_required\">*<\/span><\/label>\r\n\t\t\t\t\t\t\t\t\t<p class=\"et_pb_contact_field\" data-type=\"input\">\r\n\t\t\t<input type=\"hidden\" name=\"field_title[]\" value=\"1. Voornaam\"\/><input type=\"hidden\" name=\"field_name[]\" value=\"de_fb_6\"\/><input type=\"hidden\" name=\"field_id[]\" value=\"de_fb_6\"\/>\t\t\t\t\t\t\t<input type=\"text\" name=\"de_fb_6\" id=\"de_fb_6_fk_9\" data-calc_default=\"0\" placeholder=\"Voer uw antwoord in\"   class=\"divi-form-builder-field input-field \" required value=\"\"  data-msg-required=\"Verplicht invullen aub\" data-required_position=\"bottom\" autocomplete=\"on\" \/>\r\n\t\t\t\t\t\t\t\t\t<\/p>\r\n\r\n\t\t\t\t\t<\/div>\r\n\n\t\t\t\t<\/div>\n\t\t\t<\/div><div class=\"et_pb_module de_fb_form_field de_fb_form_field_10 dfb_radio_default clearfix  grid_et_pb_column_2_3_12 et_pb_column_2_3 et_pb_column\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t\t\t<div id=\"de_fb_7_fk_10_wrapper\" class=\"field_wrapper search_filter_cont \" data-count=\"60\" >\r\n\t\t\t\t\t<label for=\"de_fb_7_fk_10\" class=\"field_label\">1. Voornaam <span class=\"de_fb_required\"><\/span><\/label>\r\n\t\t\t\t\t\t\t\t\t<p class=\"et_pb_contact_field\" data-type=\"radio\">\r\n\t\t\t<input type=\"hidden\" name=\"field_title[]\" value=\"1. Voornaam\"\/><input type=\"hidden\" name=\"field_name[]\" value=\"de_fb_7\"\/><input type=\"hidden\" name=\"field_id[]\" value=\"de_fb_7\"\/><span class=\"et_pb_contact_field_options_wrapper\">\r\n\t\t\t\t\t\t\t\t<span class=\"et_pb_contact_field_options_list \"  data-required_message=\"Verplicht invullen aub\" data-required_position=\"bottom\"><span class=\"et_pb_contact_field_checkbox\">\r\n\t\t\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_de_fb_7_fk_10_10_0\" class=\"divi-form-builder-field radio-field\" name=\"de_fb_7\" value=\"M\" data-id=\"M\">\r\n\t\t\t\t\t\t\t\t\t\t<label class=\"\" for=\"et_pb_contact_de_fb_7_fk_10_10_0\">\r\n\t\t\t\t\t\t\t\t\t\t\t<i><\/i>\r\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"label_wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t\t\t<span>Pati\u00ebnt<\/span>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t\t\t\t\t<\/span><span class=\"et_pb_contact_field_checkbox\">\r\n\t\t\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_de_fb_7_fk_10_10_1\" class=\"divi-form-builder-field radio-field\" name=\"de_fb_7\" value=\"F\" data-id=\"F\">\r\n\t\t\t\t\t\t\t\t\t\t<label class=\"\" for=\"et_pb_contact_de_fb_7_fk_10_10_1\">\r\n\t\t\t\t\t\t\t\t\t\t\t<i><\/i>\r\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"label_wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t\t\t<span>Huisarts<\/span>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t\t\t\t\t<\/span><span class=\"et_pb_contact_field_checkbox\">\r\n\t\t\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_de_fb_7_fk_10_10_2\" class=\"divi-form-builder-field radio-field\" name=\"de_fb_7\" value=\"Otro\" data-id=\"Otro\">\r\n\t\t\t\t\t\t\t\t\t\t<label class=\"\" for=\"et_pb_contact_de_fb_7_fk_10_10_2\">\r\n\t\t\t\t\t\t\t\t\t\t\t<i><\/i>\r\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"label_wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t\t\t<span>Specialist<\/span>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t\t\t\t\t<\/span><\/span>\r\n\t\t\t\t\t\t\t<\/span>\t\t\t<\/p>\r\n\r\n\t\t\t\t\t<\/div>\r\n\n\t\t\t\t<\/div>\n\t\t\t<\/div><div class=\"et_pb_module de_fb_form_field de_fb_form_field_11 clearfix  grid_et_pb_column_2_3_12 et_pb_column_2_3 et_pb_column\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t\t\t<div id=\"de_fb_7-andere_fk_11_wrapper\" class=\"field_wrapper search_filter_cont \" data-count=\"60\" >\r\n\t\t\t\t\t\t\t\t<p class=\"et_pb_contact_field\" data-type=\"input\">\r\n\t\t\t<input type=\"hidden\" name=\"field_title[]\" value=\"7 Andere\"\/><input type=\"hidden\" name=\"field_name[]\" value=\"de_fb_7-andere\"\/><input type=\"hidden\" name=\"field_id[]\" value=\"de_fb_7-andere\"\/>\t\t\t\t\t\t\t<input type=\"text\" name=\"de_fb_7-andere\" id=\"de_fb_7-andere_fk_11\" data-calc_default=\"0\" placeholder=\"Voer uw antwoord in\"   class=\"divi-form-builder-field input-field \"  value=\"\"  autocomplete=\"on\" \/>\r\n\t\t\t\t\t\t\t\t\t<\/p>\r\n\r\n\t\t\t\t\t<\/div>\r\n\n\t\t\t\t<\/div>\n\t\t\t<\/div><div class=\"et_pb_module de_fb_form_field de_fb_form_field_12 clearfix  grid_et_pb_column_2_3_12 et_pb_column_2_3 et_pb_column\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t\t\t<div id=\"de_fb_8_fk_12_wrapper\" class=\"field_wrapper search_filter_cont \" data-count=\"60\" >\r\n\t\t\t\t\t<label for=\"de_fb_8_fk_12\" class=\"field_label\">1. Voornaam <span class=\"de_fb_required\">*<\/span><\/label>\r\n\t\t\t\t\t\t\t\t\t<p class=\"et_pb_contact_field\" data-type=\"input\">\r\n\t\t\t<input type=\"hidden\" name=\"field_title[]\" value=\"1. Voornaam\"\/><input type=\"hidden\" name=\"field_name[]\" value=\"de_fb_8\"\/><input type=\"hidden\" name=\"field_id[]\" value=\"de_fb_8\"\/>\t\t\t\t\t\t\t<input type=\"text\" name=\"de_fb_8\" id=\"de_fb_8_fk_12\" data-calc_default=\"0\" placeholder=\"Voer uw antwoord in\"   class=\"divi-form-builder-field input-field \" required value=\"\"  data-msg-required=\"Verplicht invullen aub\" data-required_position=\"bottom\" autocomplete=\"on\" \/>\r\n\t\t\t\t\t\t\t\t\t<\/p>\r\n\r\n\t\t\t\t\t<\/div>\r\n\n\t\t\t\t<\/div>\n\t\t\t<\/div><div class=\"et_pb_module de_fb_form_field de_fb_form_field_13 dfb_radio_default clearfix  grid_et_pb_column_2_3_12 et_pb_column_2_3 et_pb_column\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t\t\t<div id=\"de_fb_9_fk_13_wrapper\" class=\"field_wrapper search_filter_cont \" data-count=\"60\" >\r\n\t\t\t\t\t<label for=\"de_fb_9_fk_13\" class=\"field_label\">1. Voornaam <span class=\"de_fb_required\"><\/span><\/label>\r\n\t\t\t\t\t\t\t\t\t<p class=\"et_pb_contact_field\" data-type=\"radio\">\r\n\t\t\t<input type=\"hidden\" name=\"field_title[]\" value=\"1. Voornaam\"\/><input type=\"hidden\" name=\"field_name[]\" value=\"de_fb_9\"\/><input type=\"hidden\" name=\"field_id[]\" value=\"de_fb_9\"\/><span class=\"et_pb_contact_field_options_wrapper\">\r\n\t\t\t\t\t\t\t\t<span class=\"et_pb_contact_field_options_list \"  data-required_message=\"Verplicht invullen aub\" data-required_position=\"bottom\"><span class=\"et_pb_contact_field_checkbox\">\r\n\t\t\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_de_fb_9_fk_13_13_0\" class=\"divi-form-builder-field radio-field\" name=\"de_fb_9\" value=\"Si\" data-id=\"Si\">\r\n\t\t\t\t\t\t\t\t\t\t<label class=\"\" for=\"et_pb_contact_de_fb_9_fk_13_13_0\">\r\n\t\t\t\t\t\t\t\t\t\t\t<i><\/i>\r\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"label_wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t\t\t<span>Pati\u00ebnt<\/span>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t\t\t\t\t<\/span><span class=\"et_pb_contact_field_checkbox\">\r\n\t\t\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_de_fb_9_fk_13_13_1\" class=\"divi-form-builder-field radio-field\" name=\"de_fb_9\" value=\"Non\" data-id=\"Non\">\r\n\t\t\t\t\t\t\t\t\t\t<label class=\"\" for=\"et_pb_contact_de_fb_9_fk_13_13_1\">\r\n\t\t\t\t\t\t\t\t\t\t\t<i><\/i>\r\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"label_wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t\t\t<span>Huisarts<\/span>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t\t\t\t\t<\/span><span class=\"et_pb_contact_field_checkbox\">\r\n\t\t\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_de_fb_9_fk_13_13_2\" class=\"divi-form-builder-field radio-field\" name=\"de_fb_9\" value=\"Otro\" data-id=\"Otro\">\r\n\t\t\t\t\t\t\t\t\t\t<label class=\"\" for=\"et_pb_contact_de_fb_9_fk_13_13_2\">\r\n\t\t\t\t\t\t\t\t\t\t\t<i><\/i>\r\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"label_wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t\t\t<span>Specialist<\/span>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t\t\t\t\t<\/span><\/span>\r\n\t\t\t\t\t\t\t<\/span>\t\t\t<\/p>\r\n\r\n\t\t\t\t\t<\/div>\r\n\n\t\t\t\t<\/div>\n\t\t\t<\/div><div class=\"et_pb_module de_fb_form_field de_fb_form_field_14 clearfix  grid_et_pb_column_2_3_12 et_pb_column_2_3 et_pb_column\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t\t\t<div id=\"de_fb_9-andere_fk_14_wrapper\" class=\"field_wrapper search_filter_cont \" data-count=\"60\" >\r\n\t\t\t\t\t\t\t\t<p class=\"et_pb_contact_field\" data-type=\"input\">\r\n\t\t\t<input type=\"hidden\" name=\"field_title[]\" value=\"9 Andere\"\/><input type=\"hidden\" name=\"field_name[]\" value=\"de_fb_9-andere\"\/><input type=\"hidden\" name=\"field_id[]\" value=\"de_fb_9-andere\"\/>\t\t\t\t\t\t\t<input type=\"text\" name=\"de_fb_9-andere\" id=\"de_fb_9-andere_fk_14\" data-calc_default=\"0\" placeholder=\"Voer uw antwoord in\"   class=\"divi-form-builder-field input-field \"  value=\"\"  autocomplete=\"on\" \/>\r\n\t\t\t\t\t\t\t\t\t<\/p>\r\n\r\n\t\t\t\t\t<\/div>\r\n\n\t\t\t\t<\/div>\n\t\t\t<\/div><div class=\"et_pb_module de_fb_form_field de_fb_form_field_15 clearfix  empty_module\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t\n\t\t\t\t<\/div>\n\t\t\t<\/div><div class=\"et_pb_module de_fb_form_field de_fb_form_field_16 clearfix  grid_et_pb_column_4_4_12 et_pb_column_4_4 et_pb_column dfb_content_text_field\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t\t\t<div id=\"de_fb_voorschrijver_fk_16_wrapper\" class=\"field_wrapper search_filter_cont \" data-count=\"100\" >\r\n\t\t<\/p>\n<h3>Datos del profesional prescriptor<\/h3>\n<p>\t\t<\/div>\r\n\n\t\t\t\t<\/div>\n\t\t\t<\/div><div class=\"et_pb_module de_fb_form_field de_fb_form_field_17 clearfix  grid_et_pb_column_4_4_12 et_pb_column_4_4 et_pb_column dfb_content_text_field\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t\t\t<div id=\"de_fb_ga_verder_fk_17_wrapper\" class=\"field_wrapper search_filter_cont \" data-count=\"100\" >\r\n\t\t<\/p>\n<p><strong>Gelieve op de knop \"volgende\" te klikken<\/strong><\/p>\n<p>\t\t<\/div>\r\n\n\t\t\t\t<\/div>\n\t\t\t<\/div><div class=\"et_pb_module de_fb_form_field de_fb_form_field_18 clearfix  grid_et_pb_column_2_3_12 et_pb_column_2_3 et_pb_column\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t\t\t<div id=\"de_fb_10_fk_18_wrapper\" class=\"field_wrapper search_filter_cont \" data-count=\"60\" >\r\n\t\t\t\t\t<label for=\"de_fb_10_fk_18\" class=\"field_label\">1. Voornaam <span class=\"de_fb_required\">*<\/span><\/label>\r\n\t\t\t\t\t\t\t\t\t<p class=\"et_pb_contact_field\" data-type=\"input\">\r\n\t\t\t<input type=\"hidden\" name=\"field_title[]\" value=\"1. Voornaam\"\/><input type=\"hidden\" name=\"field_name[]\" value=\"de_fb_10\"\/><input type=\"hidden\" name=\"field_id[]\" value=\"de_fb_10\"\/>\t\t\t\t\t\t\t<input type=\"text\" name=\"de_fb_10\" id=\"de_fb_10_fk_18\" data-calc_default=\"0\" placeholder=\"Voer uw antwoord in\"   class=\"divi-form-builder-field input-field \" required value=\"\"  data-msg-required=\"Verplicht invullen aub\" data-required_position=\"bottom\" autocomplete=\"on\" \/>\r\n\t\t\t\t\t\t\t\t\t<\/p>\r\n\r\n\t\t\t\t\t<\/div>\r\n\n\t\t\t\t<\/div>\n\t\t\t<\/div><div class=\"et_pb_module de_fb_form_field de_fb_form_field_19 clearfix  grid_et_pb_column_2_3_12 et_pb_column_2_3 et_pb_column\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t\t\t<div id=\"de_fb_11_fk_19_wrapper\" class=\"field_wrapper search_filter_cont \" data-count=\"60\" >\r\n\t\t\t\t\t<label for=\"de_fb_11_fk_19\" class=\"field_label\">1. Voornaam <span class=\"de_fb_required\"><\/span><\/label>\r\n\t\t\t\t\t\t\t\t\t<p class=\"et_pb_contact_field\" data-type=\"input\">\r\n\t\t\t<input type=\"hidden\" name=\"field_title[]\" value=\"1. Voornaam\"\/><input type=\"hidden\" name=\"field_name[]\" value=\"de_fb_11\"\/><input type=\"hidden\" name=\"field_id[]\" value=\"de_fb_11\"\/>\t\t\t\t\t\t\t<input type=\"text\" name=\"de_fb_11\" id=\"de_fb_11_fk_19\" data-calc_default=\"0\" placeholder=\"Voer uw antwoord in\"   class=\"divi-form-builder-field input-field \"  value=\"\"  autocomplete=\"on\" \/>\r\n\t\t\t\t\t\t\t\t\t<\/p>\r\n\r\n\t\t\t\t\t<\/div>\r\n\n\t\t\t\t<\/div>\n\t\t\t<\/div><div class=\"et_pb_module de_fb_form_field de_fb_form_field_20 dfb_radio_default clearfix  grid_et_pb_column_2_3_12 et_pb_column_2_3 et_pb_column\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t\t\t<div id=\"de_fb_12_fk_20_wrapper\" class=\"field_wrapper search_filter_cont \" data-count=\"60\" >\r\n\t\t\t\t\t<label for=\"de_fb_12_fk_20\" class=\"field_label\">1. Voornaam <span class=\"de_fb_required\"><\/span><\/label>\r\n\t\t\t\t\t\t\t\t\t<p class=\"et_pb_contact_field\" data-type=\"radio\">\r\n\t\t\t<input type=\"hidden\" name=\"field_title[]\" value=\"1. Voornaam\"\/><input type=\"hidden\" name=\"field_name[]\" value=\"de_fb_12\"\/><input type=\"hidden\" name=\"field_id[]\" value=\"de_fb_12\"\/><span class=\"et_pb_contact_field_options_wrapper\">\r\n\t\t\t\t\t\t\t\t<span class=\"et_pb_contact_field_options_list \"  data-required_message=\"Verplicht invullen aub\" data-required_position=\"bottom\"><span class=\"et_pb_contact_field_checkbox\">\r\n\t\t\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_de_fb_12_fk_20_20_0\" class=\"divi-form-builder-field radio-field\" name=\"de_fb_12\" value=\"M\u00e9dico de cabecera\" data-id=\"M\u00e9dico de cabecera\">\r\n\t\t\t\t\t\t\t\t\t\t<label class=\"\" for=\"et_pb_contact_de_fb_12_fk_20_20_0\">\r\n\t\t\t\t\t\t\t\t\t\t\t<i><\/i>\r\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"label_wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t\t\t<span>Pati\u00ebnt<\/span>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t\t\t\t\t<\/span><span class=\"et_pb_contact_field_checkbox\">\r\n\t\t\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_de_fb_12_fk_20_20_1\" class=\"divi-form-builder-field radio-field\" name=\"de_fb_12\" value=\"Especialista\" data-id=\"Especialista\">\r\n\t\t\t\t\t\t\t\t\t\t<label class=\"\" for=\"et_pb_contact_de_fb_12_fk_20_20_1\">\r\n\t\t\t\t\t\t\t\t\t\t\t<i><\/i>\r\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"label_wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t\t\t<span>Huisarts<\/span>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t\t\t\t\t<\/span><span class=\"et_pb_contact_field_checkbox\">\r\n\t\t\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_de_fb_12_fk_20_20_2\" class=\"divi-form-builder-field radio-field\" name=\"de_fb_12\" value=\"Otro\" data-id=\"Otro\">\r\n\t\t\t\t\t\t\t\t\t\t<label class=\"\" for=\"et_pb_contact_de_fb_12_fk_20_20_2\">\r\n\t\t\t\t\t\t\t\t\t\t\t<i><\/i>\r\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"label_wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t\t\t<span>Specialist<\/span>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t\t\t\t\t<\/span><\/span>\r\n\t\t\t\t\t\t\t<\/span>\t\t\t<\/p>\r\n\r\n\t\t\t\t\t<\/div>\r\n\n\t\t\t\t<\/div>\n\t\t\t<\/div><div class=\"et_pb_module de_fb_form_field de_fb_form_field_21 clearfix  grid_et_pb_column_2_3_12 et_pb_column_2_3 et_pb_column\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t\t\t<div id=\"de_fb_12-andere_fk_21_wrapper\" class=\"field_wrapper search_filter_cont \" data-count=\"60\" >\r\n\t\t\t\t\t\t\t\t<p class=\"et_pb_contact_field\" data-type=\"input\">\r\n\t\t\t<input type=\"hidden\" name=\"field_title[]\" value=\"12 Andere\"\/><input type=\"hidden\" name=\"field_name[]\" value=\"de_fb_12-andere\"\/><input type=\"hidden\" name=\"field_id[]\" value=\"de_fb_12-andere\"\/>\t\t\t\t\t\t\t<input type=\"text\" name=\"de_fb_12-andere\" id=\"de_fb_12-andere_fk_21\" data-calc_default=\"0\" placeholder=\"Voer uw antwoord in\"   class=\"divi-form-builder-field input-field \"  value=\"\"  autocomplete=\"on\" \/>\r\n\t\t\t\t\t\t\t\t\t<\/p>\r\n\r\n\t\t\t\t\t<\/div>\r\n\n\t\t\t\t<\/div>\n\t\t\t<\/div><div class=\"et_pb_module de_fb_form_field de_fb_form_field_22 clearfix  grid_et_pb_column_2_3_12 et_pb_column_2_3 et_pb_column\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t\t\t<div id=\"de_fb_13_fk_22_wrapper\" class=\"field_wrapper search_filter_cont \" data-count=\"60\" >\r\n\t\t\t\t\t<label for=\"de_fb_13_fk_22\" class=\"field_label\">1. Voornaam <span class=\"de_fb_required\"><\/span><\/label>\r\n\t\t\t\t\t\t\t\t\t<p class=\"et_pb_contact_field\" data-type=\"input\">\r\n\t\t\t<input type=\"hidden\" name=\"field_title[]\" value=\"1. Voornaam\"\/><input type=\"hidden\" name=\"field_name[]\" value=\"de_fb_13\"\/><input type=\"hidden\" name=\"field_id[]\" value=\"de_fb_13\"\/>\t\t\t\t\t\t\t<input type=\"text\" name=\"de_fb_13\" id=\"de_fb_13_fk_22\" data-calc_default=\"0\" placeholder=\"Voer uw antwoord in\"  pattern=\"[0-9\\s]*\"  class=\"divi-form-builder-field input-field \"  value=\"\"  data-msg-pattern=\"Invalid Format.\" autocomplete=\"on\" \/>\r\n\t\t\t\t\t\t\t\t\t<\/p>\r\n\r\n\t\t\t\t\t<\/div>\r\n\n\t\t\t\t<\/div>\n\t\t\t<\/div><div class=\"et_pb_module de_fb_form_field de_fb_form_field_23 clearfix  grid_et_pb_column_2_3_12 et_pb_column_2_3 et_pb_column\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t\t\t<div id=\"de_fb_14_fk_23_wrapper\" class=\"field_wrapper search_filter_cont \" data-count=\"60\" >\r\n\t\t\t\t\t<label for=\"de_fb_14_fk_23\" class=\"field_label\">1. Voornaam <span class=\"de_fb_required\"><\/span><\/label>\r\n\t\t\t\t\t\t\t\t\t<p class=\"et_pb_contact_field\" data-type=\"input\">\r\n\t\t\t<input type=\"hidden\" name=\"field_title[]\" value=\"1. Voornaam\"\/><input type=\"hidden\" name=\"field_name[]\" value=\"de_fb_14\"\/><input type=\"hidden\" name=\"field_id[]\" value=\"de_fb_14\"\/>\t\t\t\t\t\t\t<input type=\"text\" name=\"de_fb_14\" id=\"de_fb_14_fk_23\" data-calc_default=\"0\" placeholder=\"Voer uw antwoord in\"   class=\"divi-form-builder-field input-field \"  value=\"\"  autocomplete=\"on\" \/>\r\n\t\t\t\t\t\t\t\t\t<\/p>\r\n\r\n\t\t\t\t\t<\/div>\r\n\n\t\t\t\t<\/div>\n\t\t\t<\/div><div class=\"et_pb_module de_fb_form_field de_fb_form_field_24 dfb_radio_default clearfix  grid_et_pb_column_2_3_12 et_pb_column_2_3 et_pb_column\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t\t\t<div id=\"de_fb_15_fk_24_wrapper\" class=\"field_wrapper search_filter_cont \" data-count=\"60\" >\r\n\t\t\t\t\t<label for=\"de_fb_15_fk_24\" class=\"field_label\">1. Voornaam <span class=\"de_fb_required\"><\/span><\/label>\r\n\t\t\t\t\t\t\t\t\t<p class=\"et_pb_contact_field\" data-type=\"radio\">\r\n\t\t\t<input type=\"hidden\" name=\"field_title[]\" value=\"1. Voornaam\"\/><input type=\"hidden\" name=\"field_name[]\" value=\"de_fb_15\"\/><input type=\"hidden\" name=\"field_id[]\" value=\"de_fb_15\"\/><span class=\"et_pb_contact_field_options_wrapper\">\r\n\t\t\t\t\t\t\t\t<span class=\"et_pb_contact_field_options_list \"  data-required_message=\"Verplicht invullen aub\" data-required_position=\"bottom\"><span class=\"et_pb_contact_field_checkbox\">\r\n\t\t\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_de_fb_15_fk_24_24_0\" class=\"divi-form-builder-field radio-field\" name=\"de_fb_15\" value=\"Si\" data-id=\"Si\">\r\n\t\t\t\t\t\t\t\t\t\t<label class=\"\" for=\"et_pb_contact_de_fb_15_fk_24_24_0\">\r\n\t\t\t\t\t\t\t\t\t\t\t<i><\/i>\r\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"label_wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t\t\t<span>Pati\u00ebnt<\/span>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t\t\t\t\t<\/span><span class=\"et_pb_contact_field_checkbox\">\r\n\t\t\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_de_fb_15_fk_24_24_1\" class=\"divi-form-builder-field radio-field\" name=\"de_fb_15\" value=\"Non\" data-id=\"Non\">\r\n\t\t\t\t\t\t\t\t\t\t<label class=\"\" for=\"et_pb_contact_de_fb_15_fk_24_24_1\">\r\n\t\t\t\t\t\t\t\t\t\t\t<i><\/i>\r\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"label_wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t\t\t<span>Huisarts<\/span>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t\t\t\t\t<\/span><\/span>\r\n\t\t\t\t\t\t\t<\/span>\t\t\t<\/p>\r\n\r\n\t\t\t\t\t<\/div>\r\n\n\t\t\t\t<\/div>\n\t\t\t<\/div><div class=\"et_pb_module de_fb_form_field de_fb_form_field_25 clearfix  empty_module\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t\n\t\t\t\t<\/div>\n\t\t\t<\/div><div class=\"et_pb_module de_fb_form_field de_fb_form_field_26 clearfix  grid_et_pb_column_4_4_12 et_pb_column_4_4 et_pb_column dfb_content_text_field\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t\t\t<div id=\"de_fb_geneesmiddel_fk_26_wrapper\" class=\"field_wrapper search_filter_cont \" data-count=\"100\" >\r\n\t\t<\/p>\n<h3>F\u00e1rmaco \/ Producto<\/h3>\n<p>\t\t<\/div>\r\n\n\t\t\t\t<\/div>\n\t\t\t<\/div><div class=\"et_pb_module de_fb_form_field de_fb_form_field_27 clearfix  grid_et_pb_column_2_3_12 et_pb_column_2_3 et_pb_column\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t\t\t<div id=\"de_fb_16_fk_27_wrapper\" class=\"field_wrapper search_filter_cont \" data-count=\"60\" >\r\n\t\t\t\t\t<label for=\"de_fb_16_fk_27\" class=\"field_label\">1. Voornaam <span class=\"de_fb_required\">*<\/span><\/label>\r\n\t\t\t\t\t\t\t\t\t<p class=\"et_pb_contact_field\" data-type=\"input\">\r\n\t\t\t<input type=\"hidden\" name=\"field_title[]\" value=\"1. Voornaam\"\/><input type=\"hidden\" name=\"field_name[]\" value=\"de_fb_16\"\/><input type=\"hidden\" name=\"field_id[]\" value=\"de_fb_16\"\/>\t\t\t\t\t\t\t<input type=\"text\" name=\"de_fb_16\" id=\"de_fb_16_fk_27\" data-calc_default=\"0\" placeholder=\"Voer uw antwoord in\"   class=\"divi-form-builder-field input-field \" required value=\"\"  data-msg-required=\"Verplicht invullen aub\" data-required_position=\"bottom\" autocomplete=\"on\" \/>\r\n\t\t\t\t\t\t\t\t\t<\/p>\r\n\r\n\t\t\t\t\t<\/div>\r\n\n\t\t\t\t<\/div>\n\t\t\t<\/div><div class=\"et_pb_module de_fb_form_field de_fb_form_field_28 dfb_radio_default clearfix  grid_et_pb_column_2_3_12 et_pb_column_2_3 et_pb_column\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t\t\t<div id=\"de_fb_17_fk_28_wrapper\" class=\"field_wrapper search_filter_cont \" data-count=\"60\" >\r\n\t\t\t\t\t<label for=\"de_fb_17_fk_28\" class=\"field_label\">1. Voornaam <span class=\"de_fb_required\"><\/span><\/label>\r\n\t\t\t\t\t\t\t\t\t<p class=\"et_pb_contact_field\" data-type=\"radio\">\r\n\t\t\t<input type=\"hidden\" name=\"field_title[]\" value=\"1. Voornaam\"\/><input type=\"hidden\" name=\"field_name[]\" value=\"de_fb_17\"\/><input type=\"hidden\" name=\"field_id[]\" value=\"de_fb_17\"\/><span class=\"et_pb_contact_field_options_wrapper\">\r\n\t\t\t\t\t\t\t\t<span class=\"et_pb_contact_field_options_list \"  data-required_message=\"Verplicht invullen aub\" data-required_position=\"bottom\"><span class=\"et_pb_contact_field_checkbox\">\r\n\t\t\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_de_fb_17_fk_28_28_0\" class=\"divi-form-builder-field radio-field\" name=\"de_fb_17\" value=\"Pastill\" data-id=\"Pastill\">\r\n\t\t\t\t\t\t\t\t\t\t<label class=\"\" for=\"et_pb_contact_de_fb_17_fk_28_28_0\">\r\n\t\t\t\t\t\t\t\t\t\t\t<i><\/i>\r\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"label_wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t\t\t<span>Pati\u00ebnt<\/span>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t\t\t\t\t<\/span><span class=\"et_pb_contact_field_checkbox\">\r\n\t\t\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_de_fb_17_fk_28_28_1\" class=\"divi-form-builder-field radio-field\" name=\"de_fb_17\" value=\"Liquida\" data-id=\"Liquida\">\r\n\t\t\t\t\t\t\t\t\t\t<label class=\"\" for=\"et_pb_contact_de_fb_17_fk_28_28_1\">\r\n\t\t\t\t\t\t\t\t\t\t\t<i><\/i>\r\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"label_wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t\t\t<span>Huisarts<\/span>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t\t\t\t\t<\/span><span class=\"et_pb_contact_field_checkbox\">\r\n\t\t\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_de_fb_17_fk_28_28_2\" class=\"divi-form-builder-field radio-field\" name=\"de_fb_17\" value=\"Pomada\" data-id=\"Pomada\">\r\n\t\t\t\t\t\t\t\t\t\t<label class=\"\" for=\"et_pb_contact_de_fb_17_fk_28_28_2\">\r\n\t\t\t\t\t\t\t\t\t\t\t<i><\/i>\r\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"label_wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t\t\t<span>Specialist<\/span>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t\t\t\t\t<\/span><span class=\"et_pb_contact_field_checkbox\">\r\n\t\t\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_de_fb_17_fk_28_28_3\" class=\"divi-form-builder-field radio-field\" name=\"de_fb_17\" value=\"Polvo\" data-id=\"Polvo\">\r\n\t\t\t\t\t\t\t\t\t\t<label class=\"\" for=\"et_pb_contact_de_fb_17_fk_28_28_3\">\r\n\t\t\t\t\t\t\t\t\t\t\t<i><\/i>\r\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"label_wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t\t\t<span>Apotheker<\/span>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t\t\t\t\t<\/span><span class=\"et_pb_contact_field_checkbox\">\r\n\t\t\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_de_fb_17_fk_28_28_4\" class=\"divi-form-builder-field radio-field\" name=\"de_fb_17\" value=\"Otro\" data-id=\"Otro\">\r\n\t\t\t\t\t\t\t\t\t\t<label class=\"\" for=\"et_pb_contact_de_fb_17_fk_28_28_4\">\r\n\t\t\t\t\t\t\t\t\t\t\t<i><\/i>\r\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"label_wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t\t\t<span>Verpleger<\/span>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t\t\t\t\t<\/span><\/span>\r\n\t\t\t\t\t\t\t<\/span>\t\t\t<\/p>\r\n\r\n\t\t\t\t\t<\/div>\r\n\n\t\t\t\t<\/div>\n\t\t\t<\/div><div class=\"et_pb_module de_fb_form_field de_fb_form_field_29 clearfix  grid_et_pb_column_2_3_12 et_pb_column_2_3 et_pb_column\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t\t\t<div id=\"de_fb_17-andere_fk_29_wrapper\" class=\"field_wrapper search_filter_cont \" data-count=\"60\" >\r\n\t\t\t\t\t\t\t\t<p class=\"et_pb_contact_field\" data-type=\"input\">\r\n\t\t\t<input type=\"hidden\" name=\"field_title[]\" value=\"17 Andere\"\/><input type=\"hidden\" name=\"field_name[]\" value=\"de_fb_17-andere\"\/><input type=\"hidden\" name=\"field_id[]\" value=\"de_fb_17-andere\"\/>\t\t\t\t\t\t\t<input type=\"text\" name=\"de_fb_17-andere\" id=\"de_fb_17-andere_fk_29\" data-calc_default=\"0\" placeholder=\"Voer uw antwoord in\"   class=\"divi-form-builder-field input-field \"  value=\"\"  autocomplete=\"on\" \/>\r\n\t\t\t\t\t\t\t\t\t<\/p>\r\n\r\n\t\t\t\t\t<\/div>\r\n\n\t\t\t\t<\/div>\n\t\t\t<\/div><div class=\"et_pb_module de_fb_form_field de_fb_form_field_30 clearfix  grid_et_pb_column_2_3_12 et_pb_column_2_3 et_pb_column\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t\t\t<div id=\"de_fb_18_fk_30_wrapper\" class=\"field_wrapper search_filter_cont \" data-count=\"60\" >\r\n\t\t\t\t\t<label for=\"de_fb_18_fk_30\" class=\"field_label\">1. Voornaam <span class=\"de_fb_required\"><\/span><\/label>\r\n\t\t\t\t\t\t\t\t\t<p class=\"et_pb_contact_field\" data-type=\"datepicker\">\r\n\t\t\t<input type=\"hidden\" name=\"field_title[]\" value=\"1. Voornaam\"\/><input type=\"hidden\" name=\"field_name[]\" value=\"de_fb_18\"\/><input type=\"hidden\" name=\"field_id[]\" value=\"de_fb_18\"\/>\t\t\t\t\t\t\r\n\t\t\t\t<span class=\"datepicker-wrapper\">\r\n\t\t\t\t\t<input type=\"text\" class=\"divi-form-builder-field datepicker-field\"  name=\"de_fb_18\" id=\"de_fb_18_fk_30\" placeholder=\"Voer uw antwoord in\" value=\"\"  autocomplete=\"on\" acf-date=\"\"\/>\r\n\t\t\t\t<\/span>\r\n\r\n\t\t\t\t<script>\r\n\t\t\t\t\tjQuery(document).ready(function($){\r\n\t\t\t\t\t\tvar datepicker_option = $.extend(\r\n\t\t\t\t\t\t\t{},\r\n\t\t\t\t\t\t\t$.datepicker.regional['nl'],\r\n\t\t\t\t\t\t\t{\r\n\t\t\t\t\t\t\t\tshowOn: \"both\",\r\n\t\t\t\t\t            \/\/buttonImage: datepicker_arg.img_url,\r\n\t\t\t\t\t            buttonImage: 'https:\/\/qualiphar.be\/wp-content\/plugins\/divi-form-builder\/images\/calendar.png',\r\n\t\t\t\t\t            buttonImageOnly: true,\r\n\t\t\t\t\t            buttonText: \"Select date\",\r\n\t\t\t\t\t            changeYear: true,\r\n\t\t\t\t\t\t\t\t\tyearRange: '1950:2050',\r\n\t\t\t\t\t            changeMonth: true,\r\n\t\t\t\t\t            dateFormat: \"dd-mm-yy\",\r\n\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t            beforeShow: function(input, inst) {\r\n\t\t\t\t\t\t\t\t\tvar $dp = $('#ui-datepicker-div');\r\n\t\t\t\t\t\t\t\t\t$dp.addClass(\"date_picker_30\");\r\n\t\t\t\t\t\t\t\t\t\/\/ Ensure calendar is above tab modules, sticky headers, and builder overlays (see stacking contexts).\r\n\t\t\t\t\t\t\t\t\t$dp.css('z-index', 2147483646);\r\n\t\t\t\t\t\t\t\t\tif (inst && inst.dpDiv && inst.dpDiv.length) {\r\n\t\t\t\t\t\t\t\t\t\tinst.dpDiv.css('z-index', 2147483646);\r\n\t\t\t\t\t\t\t\t\t}\r\n\t\t\t\t\t\t\t\t},\r\n\t\t\t\t\t\t\t\tonClose: function(dateText, inst ) {\r\n\t\t\t\t\t\t\t\t\t$('#ui-datepicker-div').removeClass(\"date_picker_30\");\r\n\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\tdocument.getElementById(\"de_fb_18_fk_30\").dispatchEvent(new Event('change'));\r\n\t\t\t\t\t\t\t\t}\r\n\t\t\t\t\t\t\t}\r\n\t\t\t\t\t\t);\r\n\t\t\t\t\t\t\t\t$('#de_fb_18_fk_30').datepicker( datepicker_option );\r\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t});\r\n\t\t\t\t<\/script>\r\n\t\t\t<\/p>\r\n\r\n\t\t\t\t\t<\/div>\r\n\n\t\t\t\t<\/div>\n\t\t\t<\/div><div class=\"et_pb_module de_fb_form_field de_fb_form_field_31 clearfix  grid_et_pb_column_2_3_12 et_pb_column_2_3 et_pb_column\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t\t\t<div id=\"de_fb_19_fk_31_wrapper\" class=\"field_wrapper search_filter_cont \" data-count=\"60\" >\r\n\t\t\t\t\t<label for=\"de_fb_19_fk_31\" class=\"field_label\">1. Voornaam <span class=\"de_fb_required\"><\/span><\/label>\r\n\t\t\t\t\t\t\t\t\t\t<span class=\"df_field_description_text\">\u00bfQu\u00e9 dosis del medicamento Qualiphar se utiliz\u00f3?<\/span>\r\n\t\t\t\t\t\t\t<p class=\"et_pb_contact_field\" data-type=\"input\">\r\n\t\t\t<input type=\"hidden\" name=\"field_title[]\" value=\"1. Voornaam\"\/><input type=\"hidden\" name=\"field_name[]\" value=\"de_fb_19\"\/><input type=\"hidden\" name=\"field_id[]\" value=\"de_fb_19\"\/>\t\t\t\t\t\t\t<input type=\"text\" name=\"de_fb_19\" id=\"de_fb_19_fk_31\" data-calc_default=\"0\" placeholder=\"Voer uw antwoord in\"   class=\"divi-form-builder-field input-field \"  value=\"\"  autocomplete=\"on\" \/>\r\n\t\t\t\t\t\t\t\t\t<\/p>\r\n\r\n\t\t\t\t\t<\/div>\r\n\n\t\t\t\t<\/div>\n\t\t\t<\/div><div class=\"et_pb_module de_fb_form_field de_fb_form_field_32 clearfix  grid_et_pb_column_2_3_12 et_pb_column_2_3 et_pb_column\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t\t\t<div id=\"de_fb_20_fk_32_wrapper\" class=\"field_wrapper search_filter_cont \" data-count=\"60\" >\r\n\t\t\t\t\t<label for=\"de_fb_20_fk_32\" class=\"field_label\">1. Voornaam <span class=\"de_fb_required\"><\/span><\/label>\r\n\t\t\t\t\t\t\t\t\t\t<span class=\"df_field_description_text\">Ver envase<\/span>\r\n\t\t\t\t\t\t\t<p class=\"et_pb_contact_field\" data-type=\"input\">\r\n\t\t\t<input type=\"hidden\" name=\"field_title[]\" value=\"1. Voornaam\"\/><input type=\"hidden\" name=\"field_name[]\" value=\"de_fb_20\"\/><input type=\"hidden\" name=\"field_id[]\" value=\"de_fb_20\"\/>\t\t\t\t\t\t\t<input type=\"text\" name=\"de_fb_20\" id=\"de_fb_20_fk_32\" data-calc_default=\"0\" placeholder=\"Voer uw antwoord in\"   class=\"divi-form-builder-field input-field \"  value=\"\"  autocomplete=\"on\" \/>\r\n\t\t\t\t\t\t\t\t\t<\/p>\r\n\r\n\t\t\t\t\t<\/div>\r\n\n\t\t\t\t<\/div>\n\t\t\t<\/div><div class=\"et_pb_module de_fb_form_field de_fb_form_field_33 clearfix  grid_et_pb_column_2_3_12 et_pb_column_2_3 et_pb_column\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t\t\t<div id=\"de_fb_21_fk_33_wrapper\" class=\"field_wrapper search_filter_cont \" data-count=\"60\" >\r\n\t\t\t\t\t<label for=\"de_fb_21_fk_33\" class=\"field_label\">1. Voornaam <span class=\"de_fb_required\"><\/span><\/label>\r\n\t\t\t\t\t\t\t\t\t<p class=\"et_pb_contact_field\" data-type=\"text\">\r\n\t\t\t<input type=\"hidden\" name=\"field_title[]\" value=\"1. Voornaam\"\/><input type=\"hidden\" name=\"field_name[]\" value=\"de_fb_21\"\/><input type=\"hidden\" name=\"field_id[]\" value=\"de_fb_21\"\/>\t\t\t\t\t\t\t<textarea name=\"de_fb_21\" id=\"de_fb_21_fk_33\" class=\"divi-form-builder-field textarea-field\"  placeholder=\"Voer uw antwoord in\" rows=\"8\"   autocomplete=\"on\"><\/textarea>\r\n\t\t\t\t\t\t\t\t\t\t<\/p>\r\n\r\n\t\t\t\t\t<\/div>\r\n\n\t\t\t\t<\/div>\n\t\t\t<\/div><div class=\"et_pb_module de_fb_form_field de_fb_form_field_34 clearfix  empty_module\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t\n\t\t\t\t<\/div>\n\t\t\t<\/div><div class=\"et_pb_module de_fb_form_field de_fb_form_field_35 clearfix  grid_et_pb_column_4_4_12 et_pb_column_4_4 et_pb_column dfb_content_text_field\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t\t\t<div id=\"de_fb_bijwerking_fk_35_wrapper\" class=\"field_wrapper search_filter_cont \" data-count=\"100\" >\r\n\t\t<\/p>\n<h3>Sospechas de reacciones adversas a medicamentos<\/h3>\n<p>\t\t<\/div>\r\n\n\t\t\t\t<\/div>\n\t\t\t<\/div><div class=\"et_pb_module de_fb_form_field de_fb_form_field_36 dfb_radio_default clearfix  grid_et_pb_column_2_3_12 et_pb_column_2_3 et_pb_column\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t\t\t<div id=\"de_fb_22_fk_36_wrapper\" class=\"field_wrapper search_filter_cont \" data-count=\"60\" >\r\n\t\t\t\t\t<label for=\"de_fb_22_fk_36\" class=\"field_label\">1. Voornaam <span class=\"de_fb_required\">*<\/span><\/label>\r\n\t\t\t\t\t\t\t\t\t<p class=\"et_pb_contact_field\" data-type=\"radio\">\r\n\t\t\t<input type=\"hidden\" name=\"field_title[]\" value=\"1. Voornaam\"\/><input type=\"hidden\" name=\"field_name[]\" value=\"de_fb_22\"\/><input type=\"hidden\" name=\"field_id[]\" value=\"de_fb_22\"\/><span class=\"et_pb_contact_field_options_wrapper\">\r\n\t\t\t\t\t\t\t\t<span class=\"et_pb_contact_field_options_list required\"  data-required_message=\"Verplicht invullen aub\" data-required_position=\"bottom\"><span class=\"et_pb_contact_field_checkbox\">\r\n\t\t\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_de_fb_22_fk_36_36_0\" class=\"divi-form-builder-field radio-field\" name=\"de_fb_22\" value=\"Efecto secundario\" data-id=\"Efecto secundario\" data-msg-required=\"Verplicht invullen aub\" data-required_position=\"bottom\">\r\n\t\t\t\t\t\t\t\t\t\t<label class=\"\" for=\"et_pb_contact_de_fb_22_fk_36_36_0\">\r\n\t\t\t\t\t\t\t\t\t\t\t<i><\/i>\r\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"label_wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t\t\t<span>Pati\u00ebnt<\/span>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t\t\t\t\t<\/span><span class=\"et_pb_contact_field_checkbox\">\r\n\t\t\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_de_fb_22_fk_36_36_1\" class=\"divi-form-builder-field radio-field\" name=\"de_fb_22\" value=\"Transmisi\u00f3n de una infecci\u00f3n\" data-id=\"Transmisi\u00f3n de una infecci\u00f3n\">\r\n\t\t\t\t\t\t\t\t\t\t<label class=\"\" for=\"et_pb_contact_de_fb_22_fk_36_36_1\">\r\n\t\t\t\t\t\t\t\t\t\t\t<i><\/i>\r\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"label_wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t\t\t<span>Huisarts<\/span>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t\t\t\t\t<\/span><span class=\"et_pb_contact_field_checkbox\">\r\n\t\t\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_de_fb_22_fk_36_36_2\" class=\"divi-form-builder-field radio-field\" name=\"de_fb_22\" value=\"Exposici\u00f3n durante el embarazo o la lactancia (tambi\u00e9n sin efectos secundarios)\" data-id=\"Exposici\u00f3n durante el embarazo o la lactancia (tambi\u00e9n sin efectos secundarios)\">\r\n\t\t\t\t\t\t\t\t\t\t<label class=\"\" for=\"et_pb_contact_de_fb_22_fk_36_36_2\">\r\n\t\t\t\t\t\t\t\t\t\t\t<i><\/i>\r\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"label_wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t\t\t<span>Specialist<\/span>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t\t\t\t\t<\/span><span class=\"et_pb_contact_field_checkbox\">\r\n\t\t\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_de_fb_22_fk_36_36_3\" class=\"divi-form-builder-field radio-field\" name=\"de_fb_22\" value=\"Uso indebido\" data-id=\"Uso indebido\">\r\n\t\t\t\t\t\t\t\t\t\t<label class=\"\" for=\"et_pb_contact_de_fb_22_fk_36_36_3\">\r\n\t\t\t\t\t\t\t\t\t\t\t<i><\/i>\r\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"label_wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t\t\t<span>Apotheker<\/span>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t\t\t\t\t<\/span><span class=\"et_pb_contact_field_checkbox\">\r\n\t\t\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_de_fb_22_fk_36_36_4\" class=\"divi-form-builder-field radio-field\" name=\"de_fb_22\" value=\"Abuso y\/o dependencia\" data-id=\"Abuso y\/o dependencia\">\r\n\t\t\t\t\t\t\t\t\t\t<label class=\"\" for=\"et_pb_contact_de_fb_22_fk_36_36_4\">\r\n\t\t\t\t\t\t\t\t\t\t\t<i><\/i>\r\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"label_wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t\t\t<span>Verpleger<\/span>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t\t\t\t\t<\/span><span class=\"et_pb_contact_field_checkbox\">\r\n\t\t\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_de_fb_22_fk_36_36_5\" class=\"divi-form-builder-field radio-field\" name=\"de_fb_22\" value=\"Error de medicaci\u00f3n\" data-id=\"Error de medicaci\u00f3n\">\r\n\t\t\t\t\t\t\t\t\t\t<label class=\"\" for=\"et_pb_contact_de_fb_22_fk_36_36_5\">\r\n\t\t\t\t\t\t\t\t\t\t\t<i><\/i>\r\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"label_wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t\t\t<span>Andere<\/span>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t\t\t\t\t<\/span><span class=\"et_pb_contact_field_checkbox\">\r\n\t\t\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_de_fb_22_fk_36_36_6\" class=\"divi-form-builder-field radio-field\" name=\"de_fb_22\" value=\"Sobredosis\" data-id=\"Sobredosis\">\r\n\t\t\t\t\t\t\t\t\t\t<label class=\"\" for=\"et_pb_contact_de_fb_22_fk_36_36_6\">\r\n\t\t\t\t\t\t\t\t\t\t\t<i><\/i>\r\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"label_wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t\t\t<span>Overdosis<\/span>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t\t\t\t\t<\/span><span class=\"et_pb_contact_field_checkbox\">\r\n\t\t\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_de_fb_22_fk_36_36_7\" class=\"divi-form-builder-field radio-field\" name=\"de_fb_22\" value=\"Exposici\u00f3n profesional\" data-id=\" Exposici\u00f3n profesional\">\r\n\t\t\t\t\t\t\t\t\t\t<label class=\"\" for=\"et_pb_contact_de_fb_22_fk_36_36_7\">\r\n\t\t\t\t\t\t\t\t\t\t\t<i><\/i>\r\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"label_wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t\t\t<span>Beroepsblootstelling<\/span>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t\t\t\t\t<\/span><span class=\"et_pb_contact_field_checkbox\">\r\n\t\t\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_de_fb_22_fk_36_36_8\" class=\"divi-form-builder-field radio-field\" name=\"de_fb_22\" value=\"Falta de eficacia\" data-id=\"Falta de eficacia\">\r\n\t\t\t\t\t\t\t\t\t\t<label class=\"\" for=\"et_pb_contact_de_fb_22_fk_36_36_8\">\r\n\t\t\t\t\t\t\t\t\t\t\t<i><\/i>\r\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"label_wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t\t\t<span>Gebrek aan werkzaamheid<\/span>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t\t\t\t\t<\/span><span class=\"et_pb_contact_field_checkbox\">\r\n\t\t\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_de_fb_22_fk_36_36_9\" class=\"divi-form-builder-field radio-field\" name=\"de_fb_22\" value=\"Otro\" data-id=\"Otro\">\r\n\t\t\t\t\t\t\t\t\t\t<label class=\"\" for=\"et_pb_contact_de_fb_22_fk_36_36_9\">\r\n\t\t\t\t\t\t\t\t\t\t\t<i><\/i>\r\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"label_wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t\t\t<span>Andere<\/span>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t\t\t\t\t<\/span><\/span>\r\n\t\t\t\t\t\t\t<\/span>\t\t\t<\/p>\r\n\r\n\t\t\t\t\t<\/div>\r\n\n\t\t\t\t<\/div>\n\t\t\t<\/div><div class=\"et_pb_module de_fb_form_field de_fb_form_field_37 clearfix  grid_et_pb_column_2_3_12 et_pb_column_2_3 et_pb_column\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t\t\t<div id=\"de_fb_22-andere_fk_37_wrapper\" class=\"field_wrapper search_filter_cont \" data-count=\"60\" >\r\n\t\t\t\t\t\t\t\t<p class=\"et_pb_contact_field\" data-type=\"input\">\r\n\t\t\t<input type=\"hidden\" name=\"field_title[]\" value=\"22 Andere\"\/><input type=\"hidden\" name=\"field_name[]\" value=\"de_fb_22-andere\"\/><input type=\"hidden\" name=\"field_id[]\" value=\"de_fb_22-andere\"\/>\t\t\t\t\t\t\t<input type=\"text\" name=\"de_fb_22-andere\" id=\"de_fb_22-andere_fk_37\" data-calc_default=\"0\" placeholder=\"Voer uw antwoord in\"   class=\"divi-form-builder-field input-field \"  value=\"\"  autocomplete=\"on\" \/>\r\n\t\t\t\t\t\t\t\t\t<\/p>\r\n\r\n\t\t\t\t\t<\/div>\r\n\n\t\t\t\t<\/div>\n\t\t\t<\/div><div class=\"et_pb_module de_fb_form_field de_fb_form_field_38 clearfix  grid_et_pb_column_2_3_12 et_pb_column_2_3 et_pb_column\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t\t\t<div id=\"de_fb_23_fk_38_wrapper\" class=\"field_wrapper search_filter_cont \" data-count=\"60\" >\r\n\t\t\t\t\t<label for=\"de_fb_23_fk_38\" class=\"field_label\">1. Voornaam <span class=\"de_fb_required\"><\/span><\/label>\r\n\t\t\t\t\t\t\t\t\t<p class=\"et_pb_contact_field\" data-type=\"text\">\r\n\t\t\t<input type=\"hidden\" name=\"field_title[]\" value=\"1. Voornaam\"\/><input type=\"hidden\" name=\"field_name[]\" value=\"de_fb_23\"\/><input type=\"hidden\" name=\"field_id[]\" value=\"de_fb_23\"\/>\t\t\t\t\t\t\t<textarea name=\"de_fb_23\" id=\"de_fb_23_fk_38\" class=\"divi-form-builder-field textarea-field\"  placeholder=\"Voer uw antwoord in\" rows=\"8\"   autocomplete=\"on\"><\/textarea>\r\n\t\t\t\t\t\t\t\t\t\t<\/p>\r\n\r\n\t\t\t\t\t<\/div>\r\n\n\t\t\t\t<\/div>\n\t\t\t<\/div><div class=\"et_pb_module de_fb_form_field de_fb_form_field_39 dfb_radio_default clearfix  grid_et_pb_column_2_3_12 et_pb_column_2_3 et_pb_column\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t\t\t<div id=\"de_fb_24_fk_39_wrapper\" class=\"field_wrapper search_filter_cont \" data-count=\"60\" >\r\n\t\t\t\t\t<label for=\"de_fb_24_fk_39\" class=\"field_label\">1. Voornaam <span class=\"de_fb_required\">*<\/span><\/label>\r\n\t\t\t\t\t\t\t\t\t<p class=\"et_pb_contact_field\" data-type=\"radio\">\r\n\t\t\t<input type=\"hidden\" name=\"field_title[]\" value=\"1. Voornaam\"\/><input type=\"hidden\" name=\"field_name[]\" value=\"de_fb_24\"\/><input type=\"hidden\" name=\"field_id[]\" value=\"de_fb_24\"\/><span class=\"et_pb_contact_field_options_wrapper\">\r\n\t\t\t\t\t\t\t\t<span class=\"et_pb_contact_field_options_list required\"  data-required_message=\"Verplicht invullen aub\" data-required_position=\"bottom\"><span class=\"et_pb_contact_field_checkbox\">\r\n\t\t\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_de_fb_24_fk_39_39_0\" class=\"divi-form-builder-field radio-field\" name=\"de_fb_24\" value=\"No\" data-id=\"No\" data-msg-required=\"Verplicht invullen aub\" data-required_position=\"bottom\">\r\n\t\t\t\t\t\t\t\t\t\t<label class=\"\" for=\"et_pb_contact_de_fb_24_fk_39_39_0\">\r\n\t\t\t\t\t\t\t\t\t\t\t<i><\/i>\r\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"label_wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t\t\t<span>Pati\u00ebnt<\/span>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t\t\t\t\t<\/span><span class=\"et_pb_contact_field_checkbox\">\r\n\t\t\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_de_fb_24_fk_39_39_1\" class=\"divi-form-builder-field radio-field\" name=\"de_fb_24\" value=\"Hospitalizaci\u00f3n (o prolongaci\u00f3n de la misma)\" data-id=\"Hospitalizaci\u00f3n (o prolongaci\u00f3n de la misma)\">\r\n\t\t\t\t\t\t\t\t\t\t<label class=\"\" for=\"et_pb_contact_de_fb_24_fk_39_39_1\">\r\n\t\t\t\t\t\t\t\t\t\t\t<i><\/i>\r\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"label_wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t\t\t<span>Huisarts<\/span>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t\t\t\t\t<\/span><span class=\"et_pb_contact_field_checkbox\">\r\n\t\t\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_de_fb_24_fk_39_39_2\" class=\"divi-form-builder-field radio-field\" name=\"de_fb_24\" value=\"Incapacidad laboral permanente o invalidez\" data-id=\"Incapacidad laboral permanente o invalidez\">\r\n\t\t\t\t\t\t\t\t\t\t<label class=\"\" for=\"et_pb_contact_de_fb_24_fk_39_39_2\">\r\n\t\t\t\t\t\t\t\t\t\t\t<i><\/i>\r\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"label_wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t\t\t<span>Specialist<\/span>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t\t\t\t\t<\/span><span class=\"et_pb_contact_field_checkbox\">\r\n\t\t\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_de_fb_24_fk_39_39_3\" class=\"divi-form-builder-field radio-field\" name=\"de_fb_24\" value=\"Peligro de muerte\" data-id=\"Peligro de muerte\">\r\n\t\t\t\t\t\t\t\t\t\t<label class=\"\" for=\"et_pb_contact_de_fb_24_fk_39_39_3\">\r\n\t\t\t\t\t\t\t\t\t\t\t<i><\/i>\r\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"label_wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t\t\t<span>Apotheker<\/span>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t\t\t\t\t<\/span><span class=\"et_pb_contact_field_checkbox\">\r\n\t\t\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_de_fb_24_fk_39_39_4\" class=\"divi-form-builder-field radio-field\" name=\"de_fb_24\" value=\"Anomal\u00edas cong\u00e9nitas\" data-id=\"Anomal\u00edas cong\u00e9nitas\">\r\n\t\t\t\t\t\t\t\t\t\t<label class=\"\" for=\"et_pb_contact_de_fb_24_fk_39_39_4\">\r\n\t\t\t\t\t\t\t\t\t\t\t<i><\/i>\r\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"label_wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t\t\t<span>Verpleger<\/span>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t\t\t\t\t<\/span><span class=\"et_pb_contact_field_checkbox\">\r\n\t\t\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_de_fb_24_fk_39_39_5\" class=\"divi-form-builder-field radio-field\" name=\"de_fb_24\" value=\"\u00bfOtras anomal\u00edas graves?\" data-id=\"\u00bfOtras anomal\u00edas graves?\">\r\n\t\t\t\t\t\t\t\t\t\t<label class=\"\" for=\"et_pb_contact_de_fb_24_fk_39_39_5\">\r\n\t\t\t\t\t\t\t\t\t\t\t<i><\/i>\r\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"label_wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t\t\t<span>Andere<\/span>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t\t\t\t\t<\/span><span class=\"et_pb_contact_field_checkbox\">\r\n\t\t\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_de_fb_24_fk_39_39_6\" class=\"divi-form-builder-field radio-field\" name=\"de_fb_24\" value=\"Otro\" data-id=\"Otro\">\r\n\t\t\t\t\t\t\t\t\t\t<label class=\"\" for=\"et_pb_contact_de_fb_24_fk_39_39_6\">\r\n\t\t\t\t\t\t\t\t\t\t\t<i><\/i>\r\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"label_wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t\t\t<span>Overdosis<\/span>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t\t\t\t\t<\/span><\/span>\r\n\t\t\t\t\t\t\t<\/span>\t\t\t<\/p>\r\n\r\n\t\t\t\t\t<\/div>\r\n\n\t\t\t\t<\/div>\n\t\t\t<\/div><div class=\"et_pb_module de_fb_form_field de_fb_form_field_40 clearfix  grid_et_pb_column_2_3_12 et_pb_column_2_3 et_pb_column\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t\t\t<div id=\"de_fb_24-andere_fk_40_wrapper\" class=\"field_wrapper search_filter_cont \" data-count=\"60\" >\r\n\t\t\t\t\t\t\t\t<p class=\"et_pb_contact_field\" data-type=\"input\">\r\n\t\t\t<input type=\"hidden\" name=\"field_title[]\" value=\"24 Andere\"\/><input type=\"hidden\" name=\"field_name[]\" value=\"de_fb_24-andere\"\/><input type=\"hidden\" name=\"field_id[]\" value=\"de_fb_24-andere\"\/>\t\t\t\t\t\t\t<input type=\"text\" name=\"de_fb_24-andere\" id=\"de_fb_24-andere_fk_40\" data-calc_default=\"0\" placeholder=\"Voer uw antwoord in\"   class=\"divi-form-builder-field input-field \"  value=\"\"  autocomplete=\"on\" \/>\r\n\t\t\t\t\t\t\t\t\t<\/p>\r\n\r\n\t\t\t\t\t<\/div>\r\n\n\t\t\t\t<\/div>\n\t\t\t<\/div><div class=\"et_pb_module de_fb_form_field de_fb_form_field_41 dfb_radio_default clearfix  grid_et_pb_column_2_3_12 et_pb_column_2_3 et_pb_column\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t\t\t<div id=\"de_fb_25_fk_41_wrapper\" class=\"field_wrapper search_filter_cont \" data-count=\"60\" >\r\n\t\t\t\t\t<label for=\"de_fb_25_fk_41\" class=\"field_label\">1. Voornaam <span class=\"de_fb_required\">*<\/span><\/label>\r\n\t\t\t\t\t\t\t\t\t<p class=\"et_pb_contact_field\" data-type=\"radio\">\r\n\t\t\t<input type=\"hidden\" name=\"field_title[]\" value=\"1. Voornaam\"\/><input type=\"hidden\" name=\"field_name[]\" value=\"de_fb_25\"\/><input type=\"hidden\" name=\"field_id[]\" value=\"de_fb_25\"\/><span class=\"et_pb_contact_field_options_wrapper\">\r\n\t\t\t\t\t\t\t\t<span class=\"et_pb_contact_field_options_list required\"  data-required_message=\"Verplicht invullen aub\" data-required_position=\"bottom\"><span class=\"et_pb_contact_field_checkbox\">\r\n\t\t\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_de_fb_25_fk_41_41_0\" class=\"divi-form-builder-field radio-field\" name=\"de_fb_25\" value=\"Se interrumpi\u00f3 su administraci\u00f3n\" data-id=\"Se interrumpi\u00f3 su administraci\u00f3n\" data-msg-required=\"Verplicht invullen aub\" data-required_position=\"bottom\">\r\n\t\t\t\t\t\t\t\t\t\t<label class=\"\" for=\"et_pb_contact_de_fb_25_fk_41_41_0\">\r\n\t\t\t\t\t\t\t\t\t\t\t<i><\/i>\r\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"label_wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t\t\t<span>Pati\u00ebnt<\/span>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t\t\t\t\t<\/span><span class=\"et_pb_contact_field_checkbox\">\r\n\t\t\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_de_fb_25_fk_41_41_1\" class=\"divi-form-builder-field radio-field\" name=\"de_fb_25\" value=\"Se suspendi\u00f3 temporalmente\" data-id=\"Se suspendi\u00f3 temporalmente\">\r\n\t\t\t\t\t\t\t\t\t\t<label class=\"\" for=\"et_pb_contact_de_fb_25_fk_41_41_1\">\r\n\t\t\t\t\t\t\t\t\t\t\t<i><\/i>\r\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"label_wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t\t\t<span>Huisarts<\/span>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t\t\t\t\t<\/span><span class=\"et_pb_contact_field_checkbox\">\r\n\t\t\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_de_fb_25_fk_41_41_2\" class=\"divi-form-builder-field radio-field\" name=\"de_fb_25\" value=\"Reducci\u00f3n de la dosis\" data-id=\"Reducci\u00f3n de la dosis\">\r\n\t\t\t\t\t\t\t\t\t\t<label class=\"\" for=\"et_pb_contact_de_fb_25_fk_41_41_2\">\r\n\t\t\t\t\t\t\t\t\t\t\t<i><\/i>\r\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"label_wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t\t\t<span>Specialist<\/span>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t\t\t\t\t<\/span><span class=\"et_pb_contact_field_checkbox\">\r\n\t\t\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_de_fb_25_fk_41_41_3\" class=\"divi-form-builder-field radio-field\" name=\"de_fb_25\" value=\"Aumento de la dosis\" data-id=\"Aumento de la dosis\">\r\n\t\t\t\t\t\t\t\t\t\t<label class=\"\" for=\"et_pb_contact_de_fb_25_fk_41_41_3\">\r\n\t\t\t\t\t\t\t\t\t\t\t<i><\/i>\r\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"label_wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t\t\t<span>Apotheker<\/span>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t\t\t\t\t<\/span><span class=\"et_pb_contact_field_checkbox\">\r\n\t\t\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_de_fb_25_fk_41_41_4\" class=\"divi-form-builder-field radio-field\" name=\"de_fb_25\" value=\"Sin cambios\" data-id=\"Sin cambios\">\r\n\t\t\t\t\t\t\t\t\t\t<label class=\"\" for=\"et_pb_contact_de_fb_25_fk_41_41_4\">\r\n\t\t\t\t\t\t\t\t\t\t\t<i><\/i>\r\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"label_wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t\t\t<span>Verpleger<\/span>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t\t\t\t\t<\/span><span class=\"et_pb_contact_field_checkbox\">\r\n\t\t\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_de_fb_25_fk_41_41_5\" class=\"divi-form-builder-field radio-field\" name=\"de_fb_25\" value=\"Desconocido\" data-id=\"Desconocido\">\r\n\t\t\t\t\t\t\t\t\t\t<label class=\"\" for=\"et_pb_contact_de_fb_25_fk_41_41_5\">\r\n\t\t\t\t\t\t\t\t\t\t\t<i><\/i>\r\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"label_wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t\t\t<span>Andere<\/span>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t\t\t\t\t<\/span><span class=\"et_pb_contact_field_checkbox\">\r\n\t\t\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_de_fb_25_fk_41_41_6\" class=\"divi-form-builder-field radio-field\" name=\"de_fb_25\" value=\"Otro\" data-id=\"Otro\">\r\n\t\t\t\t\t\t\t\t\t\t<label class=\"\" for=\"et_pb_contact_de_fb_25_fk_41_41_6\">\r\n\t\t\t\t\t\t\t\t\t\t\t<i><\/i>\r\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"label_wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t\t\t<span>Overdosis<\/span>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t\t\t\t\t<\/span><\/span>\r\n\t\t\t\t\t\t\t<\/span>\t\t\t<\/p>\r\n\r\n\t\t\t\t\t<\/div>\r\n\n\t\t\t\t<\/div>\n\t\t\t<\/div><div class=\"et_pb_module de_fb_form_field de_fb_form_field_42 clearfix  grid_et_pb_column_2_3_12 et_pb_column_2_3 et_pb_column\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t\t\t<div id=\"de_fb_25-andere_fk_42_wrapper\" class=\"field_wrapper search_filter_cont \" data-count=\"60\" >\r\n\t\t\t\t\t\t\t\t<p class=\"et_pb_contact_field\" data-type=\"input\">\r\n\t\t\t<input type=\"hidden\" name=\"field_title[]\" value=\"25 Andere\"\/><input type=\"hidden\" name=\"field_name[]\" value=\"de_fb_25-andere\"\/><input type=\"hidden\" name=\"field_id[]\" value=\"de_fb_25-andere\"\/>\t\t\t\t\t\t\t<input type=\"text\" name=\"de_fb_25-andere\" id=\"de_fb_25-andere_fk_42\" data-calc_default=\"0\" placeholder=\"Voer uw antwoord in\"   class=\"divi-form-builder-field input-field \"  value=\"\"  autocomplete=\"on\" \/>\r\n\t\t\t\t\t\t\t\t\t<\/p>\r\n\r\n\t\t\t\t\t<\/div>\r\n\n\t\t\t\t<\/div>\n\t\t\t<\/div><div class=\"et_pb_module de_fb_form_field de_fb_form_field_43 clearfix  grid_et_pb_column_2_3_12 et_pb_column_2_3 et_pb_column\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t\t\t<div id=\"de_fb_26_fk_43_wrapper\" class=\"field_wrapper search_filter_cont \" data-count=\"60\" >\r\n\t\t\t\t\t<label for=\"de_fb_26_fk_43\" class=\"field_label\">1. Voornaam <span class=\"de_fb_required\"><\/span><\/label>\r\n\t\t\t\t\t\t\t\t\t<p class=\"et_pb_contact_field\" data-type=\"text\">\r\n\t\t\t<input type=\"hidden\" name=\"field_title[]\" value=\"1. Voornaam\"\/><input type=\"hidden\" name=\"field_name[]\" value=\"de_fb_26\"\/><input type=\"hidden\" name=\"field_id[]\" value=\"de_fb_26\"\/>\t\t\t\t\t\t\t<textarea name=\"de_fb_26\" id=\"de_fb_26_fk_43\" class=\"divi-form-builder-field textarea-field\"  placeholder=\"Voer uw antwoord in\" rows=\"8\"   autocomplete=\"on\"><\/textarea>\r\n\t\t\t\t\t\t\t\t\t\t<\/p>\r\n\r\n\t\t\t\t\t<\/div>\r\n\n\t\t\t\t<\/div>\n\t\t\t<\/div><div class=\"et_pb_module de_fb_form_field de_fb_form_field_44 clearfix  grid_et_pb_column_2_3_12 et_pb_column_2_3 et_pb_column\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t\t\t<div id=\"de_fb_27_fk_44_wrapper\" class=\"field_wrapper search_filter_cont \" data-count=\"60\" >\r\n\t\t\t\t\t<label for=\"de_fb_27_fk_44\" class=\"field_label\">1. Voornaam <span class=\"de_fb_required\"><\/span><\/label>\r\n\t\t\t\t\t\t\t\t\t<p class=\"et_pb_contact_field\" data-type=\"text\">\r\n\t\t\t<input type=\"hidden\" name=\"field_title[]\" value=\"1. Voornaam\"\/><input type=\"hidden\" name=\"field_name[]\" value=\"de_fb_27\"\/><input type=\"hidden\" name=\"field_id[]\" value=\"de_fb_27\"\/>\t\t\t\t\t\t\t<textarea name=\"de_fb_27\" id=\"de_fb_27_fk_44\" class=\"divi-form-builder-field textarea-field\"  placeholder=\"Voer uw antwoord in\" rows=\"8\"   autocomplete=\"on\"><\/textarea>\r\n\t\t\t\t\t\t\t\t\t\t<\/p>\r\n\r\n\t\t\t\t\t<\/div>\r\n\n\t\t\t\t<\/div>\n\t\t\t<\/div><div class=\"et_pb_module de_fb_form_field de_fb_form_field_45 dfb_radio_default clearfix  grid_et_pb_column_2_3_12 et_pb_column_2_3 et_pb_column\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t\t\t<div id=\"de_fb_28_fk_45_wrapper\" class=\"field_wrapper search_filter_cont \" data-count=\"60\" >\r\n\t\t\t\t\t<label for=\"de_fb_28_fk_45\" class=\"field_label\">1. Voornaam <span class=\"de_fb_required\">*<\/span><\/label>\r\n\t\t\t\t\t\t\t\t\t<p class=\"et_pb_contact_field\" data-type=\"radio\">\r\n\t\t\t<input type=\"hidden\" name=\"field_title[]\" value=\"1. Voornaam\"\/><input type=\"hidden\" name=\"field_name[]\" value=\"de_fb_28\"\/><input type=\"hidden\" name=\"field_id[]\" value=\"de_fb_28\"\/><span class=\"et_pb_contact_field_options_wrapper\">\r\n\t\t\t\t\t\t\t\t<span class=\"et_pb_contact_field_options_list required\"  data-required_message=\"Verplicht invullen aub\" data-required_position=\"bottom\"><span class=\"et_pb_contact_field_checkbox\">\r\n\t\t\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_de_fb_28_fk_45_45_0\" class=\"divi-form-builder-field radio-field\" name=\"de_fb_28\" value=\"Qualiphar puede ponerse en contacto conmigo acerca de este efecto secundario\" data-id=\"Qualiphar puede ponerse en contacto conmigo acerca de este efecto secundario\" data-msg-required=\"Verplicht invullen aub\" data-required_position=\"bottom\">\r\n\t\t\t\t\t\t\t\t\t\t<label class=\"\" for=\"et_pb_contact_de_fb_28_fk_45_45_0\">\r\n\t\t\t\t\t\t\t\t\t\t\t<i><\/i>\r\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"label_wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t\t\t<span>Pati\u00ebnt<\/span>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t\t\t\t\t<\/span><span class=\"et_pb_contact_field_checkbox\">\r\n\t\t\t\t\t\t\t\t\t\t<input type=\"radio\" id=\"et_pb_contact_de_fb_28_fk_45_45_1\" class=\"divi-form-builder-field radio-field\" name=\"de_fb_28\" value=\"\u2022\tNo quiero que Qualiphar se ponga en contacto conmigo por este efecto secundario\" data-id=\"\u2022\tNo quiero que Qualiphar se ponga en contacto conmigo por este efecto secundario\">\r\n\t\t\t\t\t\t\t\t\t\t<label class=\"\" for=\"et_pb_contact_de_fb_28_fk_45_45_1\">\r\n\t\t\t\t\t\t\t\t\t\t\t<i><\/i>\r\n\t\t\t\t\t\t\t\t\t\t\t<span class=\"label_wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t\t\t<span>Huisarts<\/span>\r\n\t\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t\t\t\t\t<\/span><\/span>\r\n\t\t\t\t\t\t\t<\/span>\t\t\t<\/p>\r\n\r\n\t\t\t\t\t<\/div>\r\n\n\t\t\t\t<\/div>\n\t\t\t<\/div><div class=\"et_pb_module de_fb_form_field de_fb_form_field_46 clearfix  grid_et_pb_column_4_4_12 et_pb_column_4_4 et_pb_column dfb_content_text_field\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t\t\t<div id=\"de_fb_privacy_fk_46_wrapper\" class=\"field_wrapper search_filter_cont \" data-count=\"100\" >\r\n\t\t<\/p>\n<h3>Declaraci\u00f3n de privacidad<\/h3>\n<p>La informaci\u00f3n solicitada en esta p\u00e1gina puede permitirnos identificar mejor los riesgos relacionados con los f\u00e1rmacos. Esto es importante para controlar la calidad y la seguridad de nuestros productos. Los datos que introduce contienen informaci\u00f3n personal. Esta informaci\u00f3n se mantendr\u00e1 estrictamente confidencial. Sus datos personales se incluir\u00e1n en una base de datos y se remitir\u00e1n de forma an\u00f3nima a las autoridades que necesiten ser informadas sobre todos los posibles efectos secundarios de los f\u00e1rmacos. Sus datos, a excepci\u00f3n de los gubernamentales, no se facilitar\u00e1n a terceros ni se utilizar\u00e1n con fines comerciales.<\/p>\n<p>(i) Por medio del g\u00e9nero y la fecha de nacimiento del paciente, podemos comprobar si tambi\u00e9n hemos recibido la misma notificaci\u00f3n a trav\u00e9s, por ejemplo, de su m\u00e9dico o farmac\u00e9utico.<\/p>\n<p>(ii) Para tramitar un efecto secundario, necesitamos los datos de la persona que presenta la notificaci\u00f3n. Si ha formulado una pregunta, necesitamos estos datos para darle una respuesta.<\/p>\n<p>\t\t<\/div>\r\n\n\t\t\t\t<\/div>\n\t\t\t<\/div><div class=\"et_pb_module de_fb_form_field de_fb_form_field_47 dfb_radio_default clearfix  grid_et_pb_column_4_4_12 et_pb_column_4_4 et_pb_column\">\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t<div class=\"et_pb_module_inner\">\n\t\t\t\t\t\t\t<div id=\"de_fb_30_fk_47_wrapper\" class=\"field_wrapper search_filter_cont \" data-count=\"100\" >\r\n\t\t\t\t\t\t\t\t<p class=\"et_pb_contact_field\" data-type=\"checkbox\">\r\n\t\t\t<input type=\"hidden\" name=\"field_title[]\" value=\"1. Voornaam\"\/><input type=\"hidden\" name=\"field_name[]\" value=\"de_fb_30\"\/><input type=\"hidden\" name=\"field_id[]\" value=\"de_fb_30\"\/><span class=\"et_pb_contact_field_options_wrapper\">\r\n\t\t\t\t\t\t\t\t<span class=\"et_pb_contact_field_options_list required\"  data-required_message=\"Verplicht invullen aub\" data-required_position=\"bottom\"><span class=\"et_pb_contact_field_checkbox\">\r\n\t\t\t\t\t\t\t\t\t<input type=\"checkbox\" id=\"et_pb_contact_de_fb_30_fk_47_47_0\" class=\"divi-form-builder-field checkbox-field\" name=\"de_fb_30[]\" value=\"Estoy de acuerdo con la declaraci\u00f3n de privacidad\" data-id=\"Estoy de acuerdo con la declaraci\u00f3n de privacidad \" data-msg-required=\"Verplicht invullen aub\" data-required_position=\"bottom\">\r\n\t\t\t\t\t\t\t\t\t<label class=\"\" for=\"et_pb_contact_de_fb_30_fk_47_47_0\">\r\n\t\t\t\t\t\t\t\t\t\t<i><\/i>\r\n\t\t\t\t\t\t\t\t\t\t<span class=\"label_wrapper\">\r\n\t\t\t\t\t\t\t\t\t\t\t<span>Ik ga akkoord met de privacy verklaring*<\/span>\r\n\t\t\t\t\t\t\t\t\t\t\t\r\n\t\t\t\t\t\t\t\t\t\t<\/span>\r\n\t\t\t\t\t\t\t\t\t<\/label>\r\n\t\t\t\t\t\t\t\t<\/span><\/span>\r\n\t\t\t\t\t\t\t<\/span>\t\t\t<\/p>\r\n\r\n\t\t\t\t\t<\/div>\r\n\n\t\t\t\t<\/div>\n\t\t\t<\/div>[\/de_fb_form][\/et_pb_column][\/et_pb_row][\/et_pb_section]<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Todos los medicamentos tienen efectos secundarios y deben incluir un prospecto. Se entiende por efecto secundario un efecto no deseado o m\u00e9dico en un paciente que recibe tratamiento con un medicamento o preparado m\u00e9dico, que no est\u00e1 necesariamente relacionado con dicho tratamiento. Los efectos secundarios m\u00e1s frecuentes ya se conocen gracias a los estudios cl\u00ednicos. [&hellip;]<\/p>\n","protected":false},"author":3,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_et_pb_use_builder":"on","_et_pb_old_content":"<p>[et_pb_section fb_built=\"1\" _builder_version=\"4.16\" custom_padding=\"20px||||false|false\" global_colors_info=\"{}\"][et_pb_row _builder_version=\"4.16\" global_colors_info=\"{}\"][et_pb_column type=\"4_4\" _builder_version=\"4.16\" global_colors_info=\"{}\"][et_pb_text admin_label=\"titel - Onze producten\" _builder_version=\"4.19.4\" _dynamic_attributes=\"content\" global_colors_info=\"{}\"]@ET-DC@eyJkeW5hbWljIjp0cnVlLCJjb250ZW50IjoicG9zdF90aXRsZSIsInNldHRpbmdzIjp7ImJlZm9yZSI6IjxoMT4iLCJhZnRlciI6IjwvaDE+In19@[\/et_pb_text][et_pb_text _builder_version=\"4.19.5\" global_colors_info=\"{}\"]<\/p><p>Alle geneesmiddelen hebben bijwerkingen en zijn verplicht voorzien van een bijsluiter. Een bijwerking is een ongewenst of medisch voorval bij een pati\u00ebnt die een behandeling krijgt met een geneesmiddel of met een medisch preparaat en dat niet noodzakelijk verband houdt met deze behandeling. De meest voorkomende bijwerkingen zijn al bekend uit klinische studies. Sommige bijwerkingen ontdekken we pas wanneer veel verschillende mensen een geneesmiddel gebruiken. Het is ook mogelijk dat bijwerkingen pas na langdurig gebruik van het geneesmiddel ontstaan en soms ontstaan er bijwerkingen omdat een geneesmiddel in combinatie met andere geneesmiddelen gebruikt wordt.<\/p><p>Voedingssupplementen vallen onder de <a href=\"https:\/\/www.health.belgium.be\/nl\/voeding\/voedingsbeleid\/wetgevend-en-normgevend-kader\/voedingswetgeving\" target=\"_blank\" rel=\"noopener\">voedingswetgeving<\/a> omdat ze wettelijk gezien voeding zijn. Bij voedingssupplementen zijn bijsluiters niet verplicht. Desondanks kunnen ook ongewenste reacties optreden.<\/p><p>[\/et_pb_text][\/et_pb_column][\/et_pb_row][et_pb_row use_custom_gutter=\"on\" gutter_width=\"2\" _builder_version=\"4.19.4\" custom_padding=\"0px||||false|false\" global_colors_info=\"{}\"][et_pb_column type=\"4_4\" _builder_version=\"4.16\" global_colors_info=\"{}\"][et_pb_text admin_label=\"subtitel\" _builder_version=\"4.19.5\" text_font=\"Rubrik SemiBold|100|||||||\" text_font_size=\"26px\" text_line_height=\"1.72em\" header_3_line_height=\"1.2em\" custom_padding=\"|50px|||false|false\" text_font_size_phone=\"20px\" text_font_size_last_edited=\"off|tablet\" header_3_font_size_tablet=\"\" header_3_font_size_phone=\"20px\" header_3_font_size_last_edited=\"on|phone\" global_colors_info=\"{}\"]<\/p><h3>Het belang van een bijwerking melden<\/h3><p>[\/et_pb_text][et_pb_text _builder_version=\"4.19.5\" custom_margin=\"||40px||false|false\" global_colors_info=\"{}\"]<\/p><p>Qualiphar bewaakt de veiligheid van geneesmiddelen door alle spontane meldingen van pati\u00ebnten of zorgverleners te verzamelen en te onderzoeken. We hebben ook de wettelijke verplichting om alles geanonimiseerd in een internationale databank te verzamelen. In deze internationale databank verzamelen alle landen informatie over bijwerkingen van geneesmiddelen. Als farmaceutische bedrijf worden we regelmatig door het <a href=\"https:\/\/www.fagg.be\/nl\/melden_van_een_bijwerking_als_patient\" target=\"_blank\" rel=\"noopener\">Federaal Agentschap voor Geneesmiddelen en Gezondheidsproducten (FAGG)<\/a> gecontroleerd. Daarom is het belangrijk om altijd uw bijwerking te melden.<\/p><p>[\/et_pb_text][et_pb_text admin_label=\"subtitel\" _builder_version=\"4.19.5\" text_font=\"Rubrik SemiBold|100|||||||\" text_font_size=\"26px\" text_line_height=\"1.72em\" header_3_line_height=\"1.2em\" header_3_font_size_tablet=\"\" header_3_font_size_phone=\"20px\" header_3_font_size_last_edited=\"on|phone\" global_colors_info=\"{}\"]<\/p><h3>Hoe meld ik een bijwerking?<\/h3><p>[\/et_pb_text][et_pb_text admin_label=\"Tekst\" _builder_version=\"4.19.5\" custom_margin=\"||40px||false|false\" global_colors_info=\"{}\"]<\/p><p>Om ons te helpen snel en effectief uw informatie te verwerken, vragen wij u om zoveel mogelijk relevante informatie te melden via <a href=\"#contactform\">onderstaand formulier<\/a>. U dient minstens volgende informatie te verstrekken:<\/p><ul><li>De contactinformatie van de melder, namelijk de persoon die de melding doet.<\/li><li>De initialen van de persoon die de mogelijke bijwerking heeft ervaren en\/of andere persoonsgegevens, zoals geslacht, geboortedatum of leeftijd of leeftijdsgroep (bv volwassenen, oudere, kind, baby).<\/li><li>De naam van het geneesmiddel of product van Qualiphar<\/li><li>Een beschrijving van de mogelijke bijwerking, zoals de ervaren symptomen, de datum waarop de mogelijke bijwerking voor het eerst optrad en de uitkomst van de mogelijke bijwerking, kortom zoveel mogelijk info die reeds beschikbaar is.<\/li><\/ul><p>[\/et_pb_text][et_pb_text admin_label=\"subtitel\" _builder_version=\"4.19.5\" text_font=\"Rubrik SemiBold|100|||||||\" text_font_size=\"26px\" text_line_height=\"1.72em\" header_3_line_height=\"1.2em\" header_3_font_size_tablet=\"\" header_3_font_size_phone=\"20px\" header_3_font_size_last_edited=\"on|phone\" global_colors_info=\"{}\"]<\/p><h3>Wat gebeurt er met uw melding?<\/h3><p>[\/et_pb_text][et_pb_text _builder_version=\"4.19.5\" custom_margin=\"||40px||false|false\" global_colors_info=\"{}\"]<\/p><ol><li>Onze collega\u2019s van de dienst Pharmacovigilantie verzamelen, registreren en analyseren elke individuele melding.<\/li><li>Wanneer een bijwerking gemeld wordt, is het mogelijk dat Qualiphar bepaalde persoonlijke informatie verzamelt. U vindt hierover meer informatie in de <a href=\"https:\/\/qualiphar.be\/privacy-policy\/\">privacy policy<\/a>.<\/li><li>Elke bijwerking wordt geanonimiseerd en in de lokale databank opgeladen. Indien genoeg gegevens voorhanden zijn, moeten ze ook in de internationale databank worden opgeladen waar ze bekeken worden door de autoriteiten. Experten evalueren die bijwerkingen zodat er actie ondernomen kan worden waar nodig, bijvoorbeeld door de bijsluiter aan te passen of zorgverleners te waarschuwen.<\/li><\/ol><p>Indien u vragen heeft over bijwerkingen met producten van Qualiphar kunt u uiteraard ook Qualiphar rechtstreeks <a href=\"https:\/\/qualiphar.be\/contact\/\">contacteren<\/a>. U mag ook de bijwerking rechtstreeks melden aan het Federaal Agentschap voor Geneesmiddelen en Gezondheidsproducten (FAGG) door te surfen naar <a href=\"https:\/\/www.fagg.be\/nl\/bijwerking\" target=\"_blank\" rel=\"noopener\">www.eenbijwerkingmelden.be<\/a>.<\/p><p>[\/et_pb_text][\/et_pb_column][\/et_pb_row][et_pb_row disabled_on=\"off|off|off\" module_id=\"contactform\" _builder_version=\"4.19.5\" _module_preset=\"default\" background_color=\"#efefef\" custom_padding=\"|75px||75px|false|true\" global_colors_info=\"{}\"][et_pb_column type=\"4_4\" _builder_version=\"4.19.4\" _module_preset=\"default\" global_colors_info=\"{}\"][de_fb_form title=\"Meld een bijwerking\" submit_button_text=\"Verzenden\" scrollto_form_after_submit=\"off\" redirect_after_success=\"on\" redirect_url_after_submission=\"@ET-DC@eyJkeW5hbWljIjp0cnVlLCJjb250ZW50IjoicG9zdF9saW5rX3VybF9wYWdlIiwic2V0dGluZ3MiOnsicG9zdF9pZCI6IjE3OTgyIn19@\" failed_message=\"Vul het formulier correct in aub%%message%%\" use_custom_email=\"off\" custom_contact_email=\"pharmacovigilance@qualiphar.com\" from_name=\"custom\" custom_from_name=\"Pharmacovigilance Qualiphar\" from_email=\"custom\" custom_from_email=\"pharmacovigilance@qualiphar.com\" send_copy_to_sender=\"on\" sender_email_field=\"4\" reply_from_name=\"custom\" reply_custom_from_name=\"Pharmacovigilance Qualiphar\" reply_from_email=\"custom\" reply_custom_from_email=\"pharmacovigilance@qualiphar.com\" reply_to_name=\"Pharmacovigilance Qualiphar\" reply_to_email=\"pharmacovigilance@qualiphar.com\" reply_email_title=\"Melding bijwerking Qualiphar product\" radio_checkbox_checked_color=\"#000000\" multistep_enabled=\"on\" multistep_form_transition=\"none\" multistep_progress_bar_style=\"lollipop\" multistep_progress_bar_inactive_color=\"#FFFFFF\" multistep_show_progress_bar_percentage=\"on\" use_honeypot_captcha=\"off\" _builder_version=\"4.19.5\" _dynamic_attributes=\"redirect_url_after_submission\" _module_preset=\"default\" form_field_background_color=\"#FFFFFF\" form_field_text_color=\"#000000\" label_text_text_color=\"#000000\" custom_button=\"on\" button_text_color=\"#FFFFFF\" button_bg_color=\"#00574a\" button_border_color=\"RGBA(255,255,255,0)\" button_border_radius=\"5px\" custom_previous_step_button=\"on\" previous_step_button_text_color=\"#FFFFFF\" previous_step_button_bg_color=\"#53af32\" previous_step_button_border_color=\"RGBA(255,255,255,0)\" previous_step_button_border_radius=\"5px\" previous_step_button_icon=\"D||divi||400\" previous_step_button_icon_color=\"#FFFFFF\" previous_step_button_icon_placement=\"left\" previous_step_button_on_hover=\"off\" custom_next_step_button=\"on\" next_step_button_text_color=\"#FFFFFF\" next_step_button_bg_color=\"#53af32\" next_step_button_border_color=\"RGBA(255,255,255,0)\" next_step_button_border_radius=\"5px\" next_step_button_icon=\"E||divi||400\" next_step_button_icon_color=\"#FFFFFF\" next_step_button_on_hover=\"off\" hover_enabled=\"0\" global_colors_info=\"{}\" sticky_enabled=\"0\"][de_fb_form_field field_title=\"Step one\" field_id=\"step-1\" field_type=\"step\" step_prev_text=\"Vorige\" step_next_text=\"Volgende\" _builder_version=\"4.19.5\" _module_preset=\"default\" global_colors_info=\"{}\"][\/de_fb_form_field][de_fb_form_field field_title=\"Contactgegevens melder\" field_id=\"melder\" field_type=\"html_content\" html_content_editor=\"<\/p><h3>Contactgegevens melder<\/h3><p>\" _builder_version=\"4.19.5\" _module_preset=\"default\" custom_margin=\"40px||||false|false\" global_colors_info=\"{}\"][\/de_fb_form_field][de_fb_form_field field_title=\"1. Voornaam\" field_id=\"1\" required_mark=\"on\" required_message=\"Verplicht invullen aub\" field_grid_column=\"et_pb_column_2_3\" field_label_position=\"top\" field_placeholder=\"Voer uw antwoord in\" _builder_version=\"4.19.5\" _module_preset=\"default\" global_colors_info=\"{}\"][\/de_fb_form_field][de_fb_form_field field_title=\"2. Familienaam\" field_id=\"2_2\" required_mark=\"on\" required_message=\"Verplicht invullen aub\" field_grid_column=\"et_pb_column_2_3\" field_label_position=\"top\" field_placeholder=\"Voer uw antwoord in\" _builder_version=\"4.19.5\" _module_preset=\"default\" global_colors_info=\"{}\"][\/de_fb_form_field][de_fb_form_field field_title=\"3. Telefoon\" field_id=\"3_2\" allowed_symbols=\"numbers\" field_grid_column=\"et_pb_column_2_3\" field_label_position=\"top\" field_placeholder=\"Voer uw antwoord in\" _builder_version=\"4.19.5\" _module_preset=\"default\" global_colors_info=\"{}\"][\/de_fb_form_field][de_fb_form_field field_title=\"4. Email\" field_id=\"4\" required_mark=\"on\" required_message=\"Verplicht invullen aub\" field_grid_column=\"et_pb_column_2_3\" field_label_position=\"top\" field_placeholder=\"Voer uw antwoord in\" _builder_version=\"4.19.5\" _module_preset=\"default\" global_colors_info=\"{}\"][\/de_fb_form_field][de_fb_form_field field_title=\"5. Ik ben de\" field_id=\"5\" field_type=\"radio\" radio_options=\"%91{%22value%22:%22Pati\u00ebnt%22,%22checked%22:0,%22dragID%22:-1},{%22value%22:%22Huisarts%22,%22checked%22:0,%22dragID%22:0},{%22value%22:%22Specialist%22,%22checked%22:0,%22dragID%22:1},{%22value%22:%22Apotheker%22,%22checked%22:0,%22dragID%22:2},{%22value%22:%22Verpleger%22,%22checked%22:0,%22dragID%22:3},{%22value%22:%22Andere%22,%22checked%22:0,%22dragID%22:4}%93\" required_mark=\"on\" required_message=\"Verplicht invullen aub\" field_grid_column=\"et_pb_column_2_3\" field_label_position=\"top\" _builder_version=\"4.19.5\" _module_preset=\"default\" global_colors_info=\"{}\"][\/de_fb_form_field][de_fb_form_field field_title=\"5-Andere\" field_id=\"5-andere\" field_grid_column=\"et_pb_column_2_3\" field_placeholder=\"Voer uw antwoord in\" conditional_logic=\"on\" conditional_logic_rules=\"%91{%22field%22:%225%22,%22condition%22:%22is%22,%22value%22:%22Andere%22}%93\" _builder_version=\"4.19.5\" _module_preset=\"default\" custom_padding=\"0px||||false|false\" global_colors_info=\"{}\"][\/de_fb_form_field][de_fb_form_field field_title=\"Step two\" field_id=\"step-2\" field_type=\"step\" step_prev_text=\"Vorige\" step_next_text=\"Volgende\" _builder_version=\"4.19.5\" _module_preset=\"default\" global_colors_info=\"{}\"][\/de_fb_form_field][de_fb_form_field field_title=\"Gegevens pati\u00ebnt\" field_id=\"pati\u00ebnt\" field_type=\"html_content\" html_content_editor=\"<\/p><h3>Gegevens pati\u00ebnt<\/h3><p>\" _builder_version=\"4.19.5\" _module_preset=\"default\" custom_margin=\"40px||||false|false\" global_colors_info=\"{}\"][\/de_fb_form_field][de_fb_form_field field_title=\"6. Initialen\" field_id=\"6\" required_mark=\"on\" required_message=\"Verplicht invuullen aub\" field_grid_column=\"et_pb_column_2_3\" field_label_position=\"top\" field_placeholder=\"Voer uw antwoord in\" _builder_version=\"4.19.5\" _module_preset=\"default\" global_colors_info=\"{}\"][\/de_fb_form_field][de_fb_form_field field_title=\"7. Geslacht\" field_id=\"7\" field_type=\"radio\" radio_options=\"%91{%22value%22:%22M%22,%22checked%22:0,%22dragID%22:-1},{%22value%22:%22V%22,%22checked%22:0,%22dragID%22:0},{%22value%22:%22Andere%22,%22checked%22:0,%22dragID%22:1}%93\" field_grid_column=\"et_pb_column_2_3\" field_label_position=\"top\" _builder_version=\"4.19.5\" _module_preset=\"default\" global_colors_info=\"{}\"][\/de_fb_form_field][de_fb_form_field field_title=\"7 Andere\" field_id=\"7-andere\" field_grid_column=\"et_pb_column_2_3\" field_placeholder=\"Voer uw antwoord in\" conditional_logic=\"on\" conditional_logic_rules=\"%91{%22field%22:%227%22,%22condition%22:%22is%22,%22value%22:%22Andere%22}%93\" _builder_version=\"4.19.5\" _module_preset=\"default\" custom_padding=\"0px||||false|false\" global_colors_info=\"{}\"][\/de_fb_form_field][de_fb_form_field field_title=\"8. Leeftijd\" field_id=\"8\" required_mark=\"on\" required_message=\"Verplicht invullen aub\" field_grid_column=\"et_pb_column_2_3\" field_label_position=\"top\" field_placeholder=\"Voer uw antwoord in\" _builder_version=\"4.19.5\" _module_preset=\"default\" global_colors_info=\"{}\"][\/de_fb_form_field][de_fb_form_field field_title=\"9. Werd het middel voorgeschreven?\" field_id=\"9\" field_type=\"radio\" radio_options=\"%91{%22value%22:%22Ja%22,%22checked%22:0,%22dragID%22:-1},{%22value%22:%22Nee%22,%22checked%22:0,%22dragID%22:0},{%22value%22:%22Andere%22,%22checked%22:0,%22dragID%22:1}%93\" field_grid_column=\"et_pb_column_2_3\" field_label_position=\"top\" _builder_version=\"4.19.5\" _module_preset=\"default\" global_colors_info=\"{}\"][\/de_fb_form_field][de_fb_form_field field_title=\"9 Andere\" field_id=\"9-andere\" field_grid_column=\"et_pb_column_2_3\" field_placeholder=\"Voer uw antwoord in\" conditional_logic=\"on\" conditional_logic_rules=\"%91{%22field%22:%229%22,%22condition%22:%22is%22,%22value%22:%22Andere%22}%93\" _builder_version=\"4.19.5\" _module_preset=\"default\" custom_padding=\"0px||||false|false\" global_colors_info=\"{}\"][\/de_fb_form_field][de_fb_form_field field_title=\"Step three\" field_id=\"step-3\" field_type=\"step\" step_prev_text=\"Vorige\" step_next_text=\"Volgende\" conditional_logic=\"on\" conditional_logic_rules=\"%91{%22field%22:%229%22,%22condition%22:%22is%22,%22value%22:%22Ja%22}%93\" _builder_version=\"4.19.5\" _module_preset=\"default\" global_colors_info=\"{}\"][\/de_fb_form_field][de_fb_form_field field_title=\"Gegevens voorschrijver\" field_id=\"voorschrijver\" field_type=\"html_content\" html_content_editor=\"<\/p><h3>Gegevens voorschrijver<\/h3><p>\" conditional_logic=\"on\" conditional_logic_rules=\"%91{%22field%22:%229%22,%22condition%22:%22is%22,%22value%22:%22Ja%22}%93\" _builder_version=\"4.19.5\" _module_preset=\"default\" custom_margin=\"40px||||false|false\" hover_enabled=\"0\" global_colors_info=\"{}\" sticky_enabled=\"0\"][\/de_fb_form_field][de_fb_form_field field_title=\"Ga verder\" field_id=\"ga_verder\" field_type=\"html_content\" html_content_editor=\"<\/p><p><strong>Gelieve op de knop %22volgende%22 te klikken<\/strong><\/p><p>\" conditional_logic=\"on\" conditional_logic_rules=\"%91{%22field%22:%229%22,%22condition%22:%22is%22,%22value%22:%22Nee%22},{%22field%22:%229%22,%22condition%22:%22is%22,%22value%22:%22Andere%22}%93\" _builder_version=\"4.19.5\" _module_preset=\"default\" custom_margin=\"40px||||false|false\" global_colors_info=\"{}\"][\/de_fb_form_field][de_fb_form_field field_title=\"10. Naam voorschrijver\" field_id=\"10\" required_mark=\"on\" required_message=\"Verplicht invullen aub\" field_grid_column=\"et_pb_column_2_3\" field_label_position=\"top\" field_placeholder=\"Voer uw antwoord in\" conditional_logic=\"on\" conditional_logic_rules=\"%91{%22field%22:%229%22,%22condition%22:%22is%22,%22value%22:%22Ja%22}%93\" _builder_version=\"4.19.5\" _module_preset=\"default\" global_colors_info=\"{}\"][\/de_fb_form_field][de_fb_form_field field_title=\"11. Naam instelling\" field_id=\"11\" field_grid_column=\"et_pb_column_2_3\" field_label_position=\"top\" field_placeholder=\"Voer uw antwoord in\" conditional_logic=\"on\" conditional_logic_rules=\"%91{%22field%22:%229%22,%22condition%22:%22is%22,%22value%22:%22Ja%22}%93\" _builder_version=\"4.19.5\" _module_preset=\"default\" global_colors_info=\"{}\"][\/de_fb_form_field][de_fb_form_field field_title=\"12. Beroep \/ Specialisme\" field_id=\"12\" field_type=\"radio\" radio_options=\"%91{%22value%22:%22Huisarts%22,%22checked%22:0,%22dragID%22:-1},{%22value%22:%22Specialist%22,%22checked%22:0,%22dragID%22:0},{%22value%22:%22Andere%22,%22checked%22:0,%22dragID%22:1}%93\" field_grid_column=\"et_pb_column_2_3\" field_label_position=\"top\" field_placeholder=\"Voer uw antwoord in\" conditional_logic=\"on\" conditional_logic_rules=\"%91{%22field%22:%229%22,%22condition%22:%22is%22,%22value%22:%22Ja%22}%93\" _builder_version=\"4.19.5\" _module_preset=\"default\" global_colors_info=\"{}\"][\/de_fb_form_field][de_fb_form_field field_title=\"12 Andere\" field_id=\"12-andere\" field_grid_column=\"et_pb_column_2_3\" field_placeholder=\"Voer uw antwoord in\" conditional_logic=\"on\" conditional_logic_rules=\"%91{%22field%22:%2212%22,%22condition%22:%22is%22,%22value%22:%22Andere%22}%93\" _builder_version=\"4.19.5\" _module_preset=\"default\" custom_padding=\"0px||||false|false\" global_colors_info=\"{}\"][\/de_fb_form_field][de_fb_form_field field_title=\"13. Telefoon\" field_id=\"13\" allowed_symbols=\"numbers\" field_grid_column=\"et_pb_column_2_3\" field_label_position=\"top\" field_placeholder=\"Voer uw antwoord in\" conditional_logic=\"on\" conditional_logic_rules=\"%91{%22field%22:%229%22,%22condition%22:%22is%22,%22value%22:%22Ja%22}%93\" _builder_version=\"4.19.5\" _module_preset=\"default\" global_colors_info=\"{}\"][\/de_fb_form_field][de_fb_form_field field_title=\"14. Email\" field_id=\"14\" field_grid_column=\"et_pb_column_2_3\" field_label_position=\"top\" field_placeholder=\"Voer uw antwoord in\" conditional_logic=\"on\" conditional_logic_rules=\"%91{%22field%22:%229%22,%22condition%22:%22is%22,%22value%22:%22Ja%22}%93\" _builder_version=\"4.19.5\" _module_preset=\"default\" global_colors_info=\"{}\"][\/de_fb_form_field][de_fb_form_field field_title=\"15. Ik geef Qualiphar toestemming om over deze bijwerking contact op te nemen met mijn voorschrijver\" field_id=\"15\" field_type=\"radio\" radio_options=\"%91{%22value%22:%22Ja%22,%22checked%22:0,%22dragID%22:-1},{%22value%22:%22Nee%22,%22checked%22:0,%22dragID%22:0}%93\" field_grid_column=\"et_pb_column_2_3\" field_label_position=\"top\" field_placeholder=\"Voer uw antwoord in\" conditional_logic=\"on\" conditional_logic_rules=\"%91{%22field%22:%229%22,%22condition%22:%22is%22,%22value%22:%22Ja%22}%93\" _builder_version=\"4.19.5\" _module_preset=\"default\" global_colors_info=\"{}\"][\/de_fb_form_field][de_fb_form_field field_title=\"Step four\" field_id=\"step-4\" field_type=\"step\" step_prev_text=\"Vorige\" step_next_text=\"Volgende\" _builder_version=\"4.19.5\" _module_preset=\"default\" global_colors_info=\"{}\"][\/de_fb_form_field][de_fb_form_field field_title=\"Geneesmiddel \/ Product\" field_id=\"geneesmiddel\" field_type=\"html_content\" html_content_editor=\"<\/p><h3>Geneesmiddel \/ Product<\/h3><p>\" _builder_version=\"4.19.5\" _module_preset=\"default\" custom_margin=\"40px||||false|false\" global_colors_info=\"{}\"][\/de_fb_form_field][de_fb_form_field field_title=\"16. Naam Geneesmiddel \/ Product\" field_id=\"16\" required_mark=\"on\" required_message=\"Verplicht invullen aub\" field_grid_column=\"et_pb_column_2_3\" field_label_position=\"top\" field_placeholder=\"Voer uw antwoord in\" _builder_version=\"4.19.5\" _module_preset=\"default\" global_colors_info=\"{}\"][\/de_fb_form_field][de_fb_form_field field_title=\"17. Farmaceutische vorm\" field_id=\"17\" field_type=\"radio\" radio_options=\"%91{%22value%22:%22Tablet%22,%22checked%22:0,%22dragID%22:-1},{%22value%22:%22Vloeibare vorm%22,%22checked%22:0,%22dragID%22:0},{%22value%22:%22Zalf%22,%22checked%22:0,%22dragID%22:1},{%22value%22:%22Poeder%22,%22checked%22:0,%22dragID%22:2},{%22value%22:%22Andere%22,%22checked%22:0,%22dragID%22:3}%93\" field_grid_column=\"et_pb_column_2_3\" field_label_position=\"top\" field_placeholder=\"Voer uw antwoord in\" _builder_version=\"4.19.5\" _module_preset=\"default\" global_colors_info=\"{}\"][\/de_fb_form_field][de_fb_form_field field_title=\"17 Andere\" field_id=\"17-andere\" field_grid_column=\"et_pb_column_2_3\" field_placeholder=\"Voer uw antwoord in\" conditional_logic=\"on\" conditional_logic_rules=\"%91{%22field%22:%2217%22,%22condition%22:%22is%22,%22value%22:%22Andere%22}%93\" _builder_version=\"4.19.5\" _module_preset=\"default\" custom_padding=\"0px||||false|false\" hover_enabled=\"0\" global_colors_info=\"{}\" sticky_enabled=\"0\"][\/de_fb_form_field][de_fb_form_field field_title=\"18. Startdatum gebruik geneesmiddel\" field_id=\"18\" field_type=\"datepicker\" date_time_picker_lang=\"nl\" date_format=\"dd-mm-yy\" field_grid_column=\"et_pb_column_2_3\" field_label_position=\"top\" field_placeholder=\"Voer uw antwoord in\" _builder_version=\"4.19.5\" _module_preset=\"default\" global_colors_info=\"{}\"][\/de_fb_form_field][de_fb_form_field field_title=\"19. Dosering\" field_id=\"19\" field_grid_column=\"et_pb_column_2_3\" field_label_position=\"top\" field_placeholder=\"Voer uw antwoord in\" description_text=\"on\" description_text_text=\"Welke dosis van het Qualiphar geneesmiddel werd gebruikt?\" _builder_version=\"4.19.5\" _module_preset=\"default\" field_description_line_height=\"2em\" global_colors_info=\"{}\"][\/de_fb_form_field][de_fb_form_field field_title=\"20. Lotnummer\" field_id=\"20\" field_grid_column=\"et_pb_column_2_3\" field_label_position=\"top\" field_placeholder=\"Voer uw antwoord in\" description_text=\"on\" description_text_text=\"Zie verpakking\" _builder_version=\"4.19.5\" _module_preset=\"default\" field_description_line_height=\"2em\" global_colors_info=\"{}\"][\/de_fb_form_field][de_fb_form_field field_title=\"21. Voor welke indicatie werd het geneesmiddel gebruikt?\" field_id=\"21\" field_type=\"text\" field_grid_column=\"et_pb_column_2_3\" field_label_position=\"top\" field_placeholder=\"Voer uw antwoord in\" _builder_version=\"4.19.5\" _module_preset=\"default\" field_description_text_color=\"#494949\" field_description_line_height=\"2em\" global_colors_info=\"{}\"][\/de_fb_form_field][de_fb_form_field field_title=\"Step five\" field_id=\"step-5\" field_type=\"step\" step_prev_text=\"Vorige\" step_next_text=\"Volgende\" _builder_version=\"4.19.5\" _module_preset=\"default\" global_colors_info=\"{}\"][\/de_fb_form_field][de_fb_form_field field_title=\"Bijwerking\" field_id=\"bijwerking\" field_type=\"html_content\" html_content_editor=\"<\/p><h3>Bijwerking<\/h3><p>\" _builder_version=\"4.19.5\" _module_preset=\"default\" custom_margin=\"40px||||false|false\" global_colors_info=\"{}\"][\/de_fb_form_field][de_fb_form_field field_title=\"22. Dit betreft een:\" field_id=\"22\" field_type=\"radio\" radio_options=\"%91{%22value%22:%22Bijwerking%22,%22checked%22:0,%22dragID%22:-1},{%22value%22:%22Overdracht van een infectie%22,%22checked%22:0,%22dragID%22:0},{%22value%22:%22Blootststelling tijdens zwangerschap of borstvoeding (ook zonder bijwerking)%22,%22checked%22:0,%22dragID%22:1},{%22value%22:%22Verkeerd gebruik%22,%22checked%22:0,%22dragID%22:2},{%22value%22:%22Misbruik en\/of afhankelijkheid%22,%22checked%22:0,%22dragID%22:3},{%22value%22:%22Medicatiefout%22,%22checked%22:0,%22dragID%22:4},{%22value%22:%22Overdosis%22,%22checked%22:0,%22dragID%22:5},{%22value%22:%22 Beroepsblootstelling%22,%22checked%22:0,%22dragID%22:6},{%22value%22:%22Gebrek aan werkzaamheid%22,%22checked%22:0,%22dragID%22:7},{%22value%22:%22Andere%22,%22checked%22:0,%22dragID%22:8}%93\" required_mark=\"on\" required_message=\"Verplicht invullen aub\" field_grid_column=\"et_pb_column_2_3\" field_label_position=\"top\" _builder_version=\"4.19.5\" _module_preset=\"default\" global_colors_info=\"{}\"][\/de_fb_form_field][de_fb_form_field field_title=\"22 Andere\" field_id=\"22-andere\" field_grid_column=\"et_pb_column_2_3\" field_placeholder=\"Voer uw antwoord in\" conditional_logic=\"on\" conditional_logic_rules=\"%91{%22field%22:%2222%22,%22condition%22:%22is%22,%22value%22:%22Andere%22}%93\" _builder_version=\"4.19.5\" _module_preset=\"default\" custom_padding=\"0px||||false|false\" global_colors_info=\"{}\"][\/de_fb_form_field][de_fb_form_field field_title=\"23. Beschrijving bijwerking\" field_id=\"23\" field_type=\"text\" field_grid_column=\"et_pb_column_2_3\" field_label_position=\"top\" field_placeholder=\"Voer uw antwoord in\" _builder_version=\"4.19.5\" _module_preset=\"default\" field_description_text_color=\"#494949\" field_description_line_height=\"2em\" global_colors_info=\"{}\"][\/de_fb_form_field][de_fb_form_field field_title=\"24. Heeft de bijwerking geleid tot \u00e9\u00e9n van de volgende ernstige situaties?\" field_id=\"24\" field_type=\"radio\" radio_options=\"%91{%22value%22:%22Nee%22,%22checked%22:0,%22dragID%22:-1},{%22value%22:%22Ziekenhuisopname (of verlenging hiervan)%22,%22checked%22:0,%22dragID%22:0},{%22value%22:%22Blijvende arbeidsongeschiktheid of invaliditeit%22,%22checked%22:0,%22dragID%22:1},{%22value%22:%22Levensbedreigend%22,%22checked%22:0,%22dragID%22:2},{%22value%22:%22Aangeboren afwijkingen%22,%22checked%22:0,%22dragID%22:3},{%22value%22:%22Overige ernstige afwijkingen?%22,%22checked%22:0,%22dragID%22:4},{%22value%22:%22Andere%22,%22checked%22:0,%22dragID%22:5}%93\" required_mark=\"on\" required_message=\"Verplicht invullen aub\" field_grid_column=\"et_pb_column_2_3\" field_label_position=\"top\" _builder_version=\"4.19.5\" _module_preset=\"default\" global_colors_info=\"{}\"][\/de_fb_form_field][de_fb_form_field field_title=\"24 Andere\" field_id=\"24-andere\" field_grid_column=\"et_pb_column_2_3\" field_placeholder=\"Voer uw antwoord in\" conditional_logic=\"on\" conditional_logic_rules=\"%91{%22field%22:%2224%22,%22condition%22:%22is%22,%22value%22:%22Andere%22}%93\" _builder_version=\"4.19.5\" _module_preset=\"default\" custom_padding=\"0px||||false|false\" global_colors_info=\"{}\"][\/de_fb_form_field][de_fb_form_field field_title=\"25. Werd het geneesmiddel\" field_id=\"25\" field_type=\"radio\" radio_options=\"%91{%22value%22:%22Stopgezet%22,%22checked%22:0,%22dragID%22:-1},{%22value%22:%22Tijdelijk onderbroken%22,%22checked%22:0,%22dragID%22:0},{%22value%22:%22Dosis verlaagd%22,%22checked%22:0,%22dragID%22:1},{%22value%22:%22Dosis verhoogd%22,%22checked%22:0,%22dragID%22:2},{%22value%22:%22Onveranderd%22,%22checked%22:0,%22dragID%22:3},{%22value%22:%22Onbekend%22,%22checked%22:0,%22dragID%22:4},{%22value%22:%22Andere%22,%22checked%22:0,%22dragID%22:5}%93\" required_mark=\"on\" required_message=\"Verplicht invullen aub\" field_grid_column=\"et_pb_column_2_3\" field_label_position=\"top\" _builder_version=\"4.19.5\" _module_preset=\"default\" global_colors_info=\"{}\"][\/de_fb_form_field][de_fb_form_field field_title=\"25 Andere\" field_id=\"25-andere\" field_grid_column=\"et_pb_column_2_3\" field_placeholder=\"Voer uw antwoord in\" conditional_logic=\"on\" conditional_logic_rules=\"%91{%22field%22:%2225%22,%22condition%22:%22is%22,%22value%22:%22Andere%22}%93\" _builder_version=\"4.19.5\" _module_preset=\"default\" custom_padding=\"0px||||false|false\" global_colors_info=\"{}\"][\/de_fb_form_field][de_fb_form_field field_title=\"26. Werd een behandeling voorgeschreven?\" field_id=\"26\" field_type=\"text\" field_grid_column=\"et_pb_column_2_3\" field_label_position=\"top\" field_placeholder=\"Voer uw antwoord in\" _builder_version=\"4.19.5\" _module_preset=\"default\" field_description_text_color=\"#494949\" field_description_line_height=\"2em\" global_colors_info=\"{}\"][\/de_fb_form_field][de_fb_form_field field_title=\"27. Bijkomende informatie over de bijwerking\" field_id=\"27\" field_type=\"text\" field_grid_column=\"et_pb_column_2_3\" field_label_position=\"top\" field_placeholder=\"Voer uw antwoord in\" _builder_version=\"4.19.5\" _module_preset=\"default\" field_description_text_color=\"#494949\" field_description_line_height=\"2em\" global_colors_info=\"{}\"][\/de_fb_form_field][de_fb_form_field field_title=\"28. Mag Qualiphar u contacteren over deze bijwerking?\" field_id=\"28\" field_type=\"radio\" radio_options=\"%91{%22value%22:%22Qualiphar mag contact met mij opnemen over deze bijwerking%22,%22checked%22:0,%22dragID%22:-1},{%22value%22:%22Ik wil niet dat Qualiphar contact met mij opneemt over deze bijwerking%22,%22checked%22:0,%22dragID%22:0}%93\" required_mark=\"on\" required_message=\"Verplicht invullen aub\" field_grid_column=\"et_pb_column_2_3\" field_label_position=\"top\" _builder_version=\"4.19.5\" _module_preset=\"default\" global_colors_info=\"{}\"][\/de_fb_form_field][de_fb_form_field field_title=\"Privacy\" field_id=\"privacy\" field_type=\"html_content\" html_content_editor=\"<\/p><h3>Privacy verklaring<\/h3><p>De gevraagde informatie op deze pagina kan ons in staat stellen geneesmiddel gerelateerde risico's beter te identificeren. Dit is van belang voor de bewaking van de kwaliteit en veiligheid van onze producten. De door u ingevoerde gegevens bevatten persoonlijke informatie. Deze informatie zal strikt vertrouwelijk worden behandeld. Uw persoonsgegevens zullen worden opgenomen in een database en geanonimiseerd doorgestuurd worden naar de overheden die op de hoogte gebracht moeten worden van alle mogelijke bijwerkingen van geneesmiddelen. Uw gegevens zullen, met uitzondering van de overheden, niet aan derden worden verstrekt en niet voor commerci\u00eble doeleinden worden gebruikt.<\/p><p>(i) Aan de hand van het geslacht en de geboortedatum van de pati\u00ebnt kunnen wij nagaan of wij dezelfde melding wellicht ook hebben ontvangen via bijvoorbeeld uw arts of apotheker.<\/p><p>(ii) Om een bijwerking te kunnen verwerken hebben wij gegevens nodig van degene die deze melding doet (de melder). 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