Cosmetic Adverse Reaction Report
Report an unwanted skin, eye, or other reaction linked to a cosmetic product. Please provide details about the person affected, the product used, the reaction, and any actions taken.
Reporter Information
Reporter full name
*
First Name
Middle Name
Last Name
Email address
*
example@example.com
Phone number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship to the affected person
Please Select
Self (I am the affected person)
Parent/Guardian
Spouse/Partner
Family member
Healthcare professional
Caregiver
Other
Preferred contact method
*
Email
Phone
Either
Affected Person Information
Affected Person Full Name
*
First Name
Middle Name
Last Name
Age
Sex or Gender
Female
Male
Non-binary
Prefer not to say
Prefer to self-describe
Is the Affected Person the Same as the Reporter?
*
Yes
No
Product Details
Cosmetic Product Name
*
Product Type / Category
*
Please Select
Cleanser
Moisturizer
Makeup
Fragrance
Hair Product
Sunscreen
Nail Product
Serum
Body Wash
Other
Brand / Manufacturer
*
Product Variant or Shade
Purchase Date
 -
Month
 -
Day
Year
Date
Where Purchased
Product Condition
*
New
Opened
Previously Used
Reaction Details
When did the reaction first appear?
*
 -
Month
 -
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
When was the product last used before the reaction?
 -
Month
 -
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Which body area(s) were affected?
*
Face
Eyes
Lips
Scalp
Hands
Arms
Torso
Legs
Feet
Other
What symptoms did you experience?
*
Redness
Itching
Burning
Swelling
Rash
Dryness
Hives
Stinging
Peeling
Blistering
Eye irritation
Breathing difficulty
Other
How severe was the reaction?
*
Mild
1
2
3
4
5
6
7
8
9
Severe
10
1 is Mild, 10 is Severe
Is the reaction still ongoing?
*
Yes
No
Unsure
Please describe what happened.
Was medical attention sought?
*
Yes
No
What type of care was received?
No care received
Pharmacist consultation
Primary care visit
Urgent care
Emergency department
Hospital admission
Other
Usage and Exposure History
How was the product used?
*
How often was the product used?
*
Please Select
Once
Daily
Several times per week
Weekly
Less than weekly
Other
Approximate amount applied
Was the product used alone or with other cosmetic or skincare products?
*
Used alone
Used with other products
Not sure
What exposure occurred after application?
Sun exposure
Heat exposure
Water exposure
None
Not sure
Was the product applied near any of the following areas?
Eyes
Lips
Scalp
Broken skin
None of the above
Not sure
Known allergies or sensitivities relevant to cosmetics
Actions Taken and Outcome
Actions Taken After the Reaction
*
Stopped using the product
Washed the affected area
Applied cream or ointment
Took medication
Contacted seller or manufacturer
Sought medical care
Other
How Did the Symptoms Change After the Reaction?
*
Improved
Worsened
Stayed the same
Unknown
Current Status
*
Please Select
Recovered
Recovering
Not yet recovered
Ongoing
Unknown
Are the Product and Packaging Available for Review?
*
Product and packaging available
Product only available
Packaging only available
Neither available
Unknown
Additional Comments
Follow-up Questions or Additional Information Needed
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