
    <div id="keesame_plugin_message"></div>
    <form id="keesame_plugin_form_pharmacovigilance" class="keesame_plugin_form">
        <div class="container">
            <div class="row">
                                <div class="col-lg-6">
                    <div class="keesame_plugin_group">
                        <h3>Produit Adwya</h3>
                        <div class="row">
                                                                                    <div class=" form-group-type-text " >
                                <div id="group_product_name" class="form-group">
                                    <label for="input_product_name" class="keesame_plugin_label required">
                                        Produit Adwya                                                                            </label>
                                                                            <input type="text" name="product_name" class="form-control " id="input_product_name" maxlength="255"   >
                                    </div>
                            </div>
                                                                                    <div class=" form-group-type-text " >
                                <div id="group_product_lot" class="form-group">
                                    <label for="input_product_lot" class="keesame_plugin_label ">
                                        N° de lot                                                                            </label>
                                                                            <input type="text" name="product_lot" class="form-control " id="input_product_lot" maxlength="45"   >
                                    </div>
                            </div>
                                                                                    <div class=" form-group-type-text " >
                                <div id="group_product_forme" class="form-group">
                                    <label for="input_product_forme" class="keesame_plugin_label required">
                                        Forme Galénique                                                                            </label>
                                                                            <input type="text" name="product_forme" class="form-control " id="input_product_forme"   >
                                    </div>
                            </div>
                                                                                    <div class=" form-group-type-text " >
                                <div id="group_product_method" class="form-group">
                                    <label for="input_product_method" class="keesame_plugin_label required">
                                        Voie d'administration                                                                            </label>
                                                                            <input type="text" name="product_method" class="form-control " id="input_product_method"   >
                                    </div>
                            </div>
                                                                                    <div class=" form-group-type-text " >
                                <div id="group_product_dosage" class="form-group">
                                    <label for="input_product_dosage" class="keesame_plugin_label required">
                                        Posologie                                                                            </label>
                                                                            <input type="text" name="product_dosage" class="form-control " id="input_product_dosage" maxlength="255"   >
                                    </div>
                            </div>
                                                                                    <div class=" form-group-type-text " >
                                <div id="group_product_indication" class="form-group">
                                    <label for="input_product_indication" class="keesame_plugin_label required">
                                        Indication                                                                            </label>
                                                                            <input type="text" name="product_indication" class="form-control " id="input_product_indication" maxlength="255"   >
                                    </div>
                            </div>
                                                                                    <div class="col-lg-6 form-group-type-date " >
                                <div id="group_product_started_at" class="form-group">
                                    <label for="input_product_started_at" class="keesame_plugin_label required">
                                        Date de début                                                                            </label>
                                                                            <input type="text" name="product_started_at" class="form-control bs-datepicker" id="input_product_started_at" >
                                    </div>
                            </div>
                                                                                    <div class="col-lg-6 form-group-type-date " >
                                <div id="group_product_ended_at" class="form-group">
                                    <label for="input_product_ended_at" class="keesame_plugin_label ">
                                        Date d'arrêt                                                                            </label>
                                                                            <input type="text" name="product_ended_at" class="form-control bs-datepicker" id="input_product_ended_at" >
                                    </div>
                            </div>
                                                    </div>
                    </div>
                </div>
                                <div class="col-lg-6">
                    <div class="keesame_plugin_group">
                        <h3>Information du notificateur</h3>
                        <div class="row">
                                                                                    <div class=" form-group-type-text " >
                                <div id="group_reporter_fullname" class="form-group">
                                    <label for="input_reporter_fullname" class="keesame_plugin_label required">
                                        Nom du notificateur                                                                            </label>
                                                                            <input type="text" name="reporter_fullname" class="form-control " id="input_reporter_fullname" maxlength="255"   >
                                    </div>
                            </div>
                                                                                    <div class=" form-group-type-select " >
                                <div id="group_reporter_function" class="form-group">
                                    <label for="input_reporter_function" class="keesame_plugin_label required">
                                        Titre                                                                            </label>
                                                                                <select name="reporter_function" class="form-control" id="input_reporter_function" style="width: 100%"  data-placeholder="Choisir une option">
        <option value=""></option>
                <option value="0" >Médecin</option>
                <option value="1" >Pharmacien</option>
                <option value="other" >Autre</option>
            </select>
                                    </div>
                            </div>
                                                                                    <div class=" form-group-type-text keesame_plugin_input_hide" data-keesame-is="conditional" data-keesame-field="reporter_function" data-keesame-value="other" >
                                <div id="group_reporter_function_other" class="form-group">
                                    <label for="input_reporter_function_other" class="keesame_plugin_label required">
                                        Spécifier autre titre                                                                            </label>
                                                                            <input type="text" name="reporter_function_other" class="form-control " id="input_reporter_function_other" maxlength="255"   >
                                    </div>
                            </div>
                                                                                    <div class=" form-group-type-textarea " >
                                <div id="group_reporter_address" class="form-group">
                                    <label for="input_reporter_address" class="keesame_plugin_label required">
                                        Adresse                                                                            </label>
                                                                            <textarea name="reporter_address" class="form-control" id="input_reporter_address" rows="6" maxlength="255" ></textarea>
                                    </div>
                            </div>
                                                                                    <div class=" form-group-type-text " >
                                <div id="group_reporter_phone" class="form-group">
                                    <label for="input_reporter_phone" class="keesame_plugin_label required">
                                        Téléphone                                                                            </label>
                                                                            <input type="text" name="reporter_phone" class="form-control " id="input_reporter_phone" maxlength="14"   >
                                    </div>
                            </div>
                                                                                    <div class=" form-group-type-email " >
                                <div id="group_reporter_email" class="form-group">
                                    <label for="input_reporter_email" class="keesame_plugin_label required">
                                        Email                                                                            </label>
                                                                            <input type="email" name="reporter_email" class="form-control " id="input_reporter_email" maxlength="255"   >
                                    </div>
                            </div>
                                                    </div>
                    </div>
                </div>
                                <div class="col-md-12">
                    <div class="keesame_plugin_group">
                        <h3>Identification du patient</h3>
                        <div class="row">
                                                                                    <div class="col-lg-6 form-group-type-text " >
                                <div id="group_patient_lastname" class="form-group">
                                    <label for="input_patient_lastname" class="keesame_plugin_label required">
                                        Nom (initiales)                                                                                    <i class="dashicons dashicons-info" data-bs-toggle="tooltip" data-bs-placement="top" data-bs-custom-class="custom-tooltip" title="3 premières lettres"></i>
                                                                            </label>
                                                                            <input type="text" name="patient_lastname" class="form-control " id="input_patient_lastname" maxlength="3"   >
                                    </div>
                            </div>
                                                                                    <div class="col-lg-6 form-group-type-text " >
                                <div id="group_patient_firstname" class="form-group">
                                    <label for="input_patient_firstname" class="keesame_plugin_label required">
                                        Prénom (initiales)                                                                                    <i class="dashicons dashicons-info" data-bs-toggle="tooltip" data-bs-placement="top" data-bs-custom-class="custom-tooltip" title="1 première lettre seulement"></i>
                                                                            </label>
                                                                            <input type="text" name="patient_firstname" class="form-control " id="input_patient_firstname" maxlength="1"   >
                                    </div>
                            </div>
                                                                                    <div class="col-lg-9 form-group-type-date " >
                                <div id="group_patient_birth" class="form-group">
                                    <label for="input_patient_birth" class="keesame_plugin_label required">
                                        Date de naissance                                                                            </label>
                                                                            <input type="text" name="patient_birth" class="form-control bs-datepicker" id="input_patient_birth" >
                                    </div>
                            </div>
                                                                                    <div class="col-lg-3 form-group-type-radio " >
                                <div id="group_patient_gender" class="form-group">
                                    <label for="input_patient_gender" class="keesame_plugin_label required">
                                        Sexe                                                                            </label>
                                                                            <div class="radio-group">
        <input type="radio" name="patient_gender" id="option_input_patient_gender_0" value="0"> <label for="option_input_patient_gender_0">Homme</label>
        <input type="radio" name="patient_gender" id="option_input_patient_gender_1" value="1"> <label for="option_input_patient_gender_1">Femme</label>
        </div>
                                    </div>
                            </div>
                                                                                    <div class="col-lg-6 form-group-type-number " >
                                <div id="group_patient_weight" class="form-group">
                                    <label for="input_patient_weight" class="keesame_plugin_label ">
                                        Poids                                                                                    <i class="dashicons dashicons-info" data-bs-toggle="tooltip" data-bs-placement="top" data-bs-custom-class="custom-tooltip" title="Indiquez le poids en kilogramme"></i>
                                                                            </label>
                                                                            <input type="number" name="patient_weight" class="form-control numeric" id="input_patient_weight" maxlength="3"   >
                                    </div>
                            </div>
                                                                                    <div class="col-lg-6 form-group-type-number " >
                                <div id="group_patient_height" class="form-group">
                                    <label for="input_patient_height" class="keesame_plugin_label ">
                                        Taille                                                                                    <i class="dashicons dashicons-info" data-bs-toggle="tooltip" data-bs-placement="top" data-bs-custom-class="custom-tooltip" title="Indiquez la taille en centimètre"></i>
                                                                            </label>
                                                                            <input type="number" name="patient_height" class="form-control numeric" id="input_patient_height" maxlength="3"   >
                                    </div>
                            </div>
                                                                                    <div class=" form-group-type-text " >
                                <div id="group_patient_function" class="form-group">
                                    <label for="input_patient_function" class="keesame_plugin_label ">
                                        Profession                                                                            </label>
                                                                            <input type="text" name="patient_function" class="form-control " id="input_patient_function" maxlength="255"   >
                                    </div>
                            </div>
                                                                                    <div class=" form-group-type-radio " >
                                <div id="group_patient_is_new_born" class="form-group">
                                    <label for="input_patient_is_new_born" class="keesame_plugin_label required">
                                        La déclaration concerne un nouveau-né?                                                                            </label>
                                                                            <div class="radio-group">
        <input type="radio" name="patient_is_new_born" id="option_input_patient_is_new_born_0" value="0"> <label for="option_input_patient_is_new_born_0">Non</label>
        <input type="radio" name="patient_is_new_born" id="option_input_patient_is_new_born_1" value="1"> <label for="option_input_patient_is_new_born_1">Oui</label>
        </div>
                                    </div>
                            </div>
                                                                                    <div class=" form-group-type-select-multiple keesame_plugin_input_hide" data-keesame-is="conditional" data-keesame-field="patient_is_new_born" data-keesame-value="1" >
                                <div id="group_patient_administration" class="form-group">
                                    <label for="input_patient_administration" class="keesame_plugin_label required">
                                        Précisez si les médicaments ont été reçus par                                                                             </label>
                                                                                <select name="patient_administration" class="form-control" id="input_patient_administration" style="width: 100%" multiple="1"  data-placeholder="Choisir une option">
        <option value=""></option>
                <option value="0" >Le nouveau-né lui-même</option>
                <option value="1" >La mère durant l'allaitement</option>
                <option value="2" >Durant la grossesse</option>
            </select>
                                    </div>
                            </div>
                                                                                    <div class=" form-group-type-text keesame_plugin_input_hide" data-keesame-is="conditional" data-keesame-field="patient_administration" data-keesame-value="2" >
                                <div id="group_patient_administration_trimester" class="form-group">
                                    <label for="input_patient_administration_trimester" class="keesame_plugin_label required">
                                        Précisez le trimestre de la grossesse                                                                            </label>
                                                                            <input type="text" name="patient_administration_trimester" class="form-control " id="input_patient_administration_trimester" maxlength="255"   >
                                    </div>
                            </div>
                                                    </div>
                    </div>
                </div>
                                <div class="col-md-12">
                    <div class="keesame_plugin_group">
                        <h3>Identification des maladies en cours et des facteurs de risque</h3>
                        <div class="row">
                                                                                    <div class=" form-group-type-textarea " >
                                <div id="group_diseases_description" class="form-group">
                                    <label for="input_diseases_description" class="keesame_plugin_label required">
                                        Identification des maladies en cours et des facteurs de risque                                                                            </label>
                                                                            <textarea name="diseases_description" class="form-control" id="input_diseases_description" rows="10" ></textarea>
                                    </div>
                            </div>
                                                    </div>
                    </div>
                </div>
                                <div class="col-md-12">
                    <div class="keesame_plugin_group">
                        <h3>Thérapies concomitantes</h3>
                        <div class="row">
                                                                                    <div class=" form-group-type-repeater " >
                                <div id="group_therapies_products" class="form-group">
                                    <label for="input_therapies_products" class="keesame_plugin_label ">
                                        Thérapies concomitantes                                                                            </label>
                                                                            <div class="keesame_plugin_help">Si d'autres médicaments ont été pris avant l'événement, le préciser dans la description détaillé de l'événement</div>
                                                                                <table class="keesame_plugin_form_table_repeater">
            <thead>
                <tr>
                    <th width="0"></th>
                                        <th>
                        <label class="keesame_plugin_label required">Produit                                                </label>
                    </th>
                                        <th>
                        <label class="keesame_plugin_label ">N° de lot                                                </label>
                    </th>
                                        <th>
                        <label class="keesame_plugin_label required">Forme Galénique                                                </label>
                    </th>
                                        <th>
                        <label class="keesame_plugin_label required">Voie d'administration                                                </label>
                    </th>
                                        <th>
                        <label class="keesame_plugin_label required">Posologie                                                </label>
                    </th>
                                        <th>
                        <label class="keesame_plugin_label required">Indication                                                </label>
                    </th>
                                        <th>
                        <label class="keesame_plugin_label required">Date de début                                                </label>
                    </th>
                                        <th>
                        <label class="keesame_plugin_label ">Date d'arrêt                                                </label>
                    </th>
                                    </tr>
            </thead>
            <tbody>
                    <tr id="row-69e3444527990" class="actions-required">
        <td>
            <div class="keesame_plugin_form_table_repeater_action">
                <a href="#" class="keesame_pforms_action" title="Supprimer cette ligne" data-action="remove" data-target="#row-69e3444527990"><i class="dashicons dashicons-minus"></i></a>
            </div>
        </td>
                <td>
                <input type="text" name="therapies_products[][69e3444527990][product_name]" class="form-control " id="field_69e3444527990_product_name" maxlength="255"   >
            </td>
                <td>
                <input type="text" name="therapies_products[][69e3444527990][product_lot]" class="form-control " id="field_69e3444527990_product_lot" maxlength="45"   >
            </td>
                <td>
                <input type="text" name="therapies_products[][69e3444527990][product_forme]" class="form-control " id="field_69e3444527990_product_forme"   >
            </td>
                <td>
                <input type="text" name="therapies_products[][69e3444527990][product_method]" class="form-control " id="field_69e3444527990_product_method"   >
            </td>
                <td>
                <input type="text" name="therapies_products[][69e3444527990][product_dosage]" class="form-control " id="field_69e3444527990_product_dosage" maxlength="255"   >
            </td>
                <td>
                <input type="text" name="therapies_products[][69e3444527990][product_indication]" class="form-control " id="field_69e3444527990_product_indication" maxlength="255"   >
            </td>
                <td>
                <input type="text" name="therapies_products[][69e3444527990][product_started_at]" class="form-control bs-datepicker" id="field_69e3444527990_product_started_at" >
            </td>
                <td>
                <input type="text" name="therapies_products[][69e3444527990][product_ended_at]" class="form-control bs-datepicker" id="field_69e3444527990_product_ended_at" >
            </td>
            </tr>
            </tbody>
            <tfoot>
                <tr>
                    <td colspan="8"><a href="#" class="btn btn-primary mt-2 keesame_pforms_action" data-action="ajax-html" data-url="https://adwya.com.tn/wp-admin/admin-ajax.php" data-ajax-action="keesame_pforms_action_add_row" data-ajax-params="{&quot;form&quot;:&quot;pharmacovigilance&quot;,&quot;key&quot;:&quot;therapies_products&quot;,&quot;parent&quot;:&quot;therapies&quot;}" data-target=".keesame_plugin_form_table_repeater tbody"><i class="dashicons dashicons-plus"></i>Ajouter une ligne</a></td>
                </tr>
            </tfoot>
        </table>
                                    </div>
                            </div>
                                                    </div>
                    </div>
                </div>
                                <div class="col-md-12">
                    <div class="keesame_plugin_group">
                        <h3>Identification de l'événement indésirable</h3>
                        <div class="row">
                                                                                    <div class=" form-group-type-textarea " >
                                <div id="group_occurrence_identification" class="form-group">
                                    <label for="input_occurrence_identification" class="keesame_plugin_label required">
                                        Identification de l'événement indésirable                                                                            </label>
                                                                            <textarea name="occurrence_identification" class="form-control" id="input_occurrence_identification" rows="10" ></textarea>
                                    </div>
                            </div>
                                                                                    <div class=" form-group-type-date " >
                                <div id="group_occurrence_started_at" class="form-group">
                                    <label for="input_occurrence_started_at" class="keesame_plugin_label required">
                                        Date de survenue                                                                            </label>
                                                                            <input type="text" name="occurrence_started_at" class="form-control bs-datepicker" id="input_occurrence_started_at" >
                                    </div>
                            </div>
                                                                                    <div class=" form-group-type-textarea " >
                                <div id="group_occurrence_description" class="form-group">
                                    <label for="input_occurrence_description" class="keesame_plugin_label required">
                                        Description de l'événement indésirable                                                                            </label>
                                                                            <div class="keesame_plugin_help">Précisez la chronologie de l'événement indésirable par rapport aux prises médicamenteuses. Décrivez les troubles cliniques et paracliniques en précisant leur date de survenue et leur évolution dans le temps. Décrivez si de tels troubles sont survenus chez ce patient antérieurement lors de la prise de médicament (à préciser) ou en dehors de toute prise médicamenteuse.</div>
                                                                            <textarea name="occurrence_description" class="form-control" id="input_occurrence_description" rows="10" ></textarea>
                                    </div>
                            </div>
                                                    </div>
                    </div>
                </div>
                            </div>
            <div class="row">
                <div class="col text-center">
                    <button type="submit" class="btn btn-large btn-primary">Envoyer</button>
                    <div id="group_form_control" class="form-group" style="visibility: hidden">
                        <label for="input_form_control" class="keesame_plugin_label">Form Control</label>
                        <input type="text" name="form_control" class="form-control " id="input_form_control" maxlength="255">
                        <input type="text" name="form_name" class="form-control " id="input_form_name" value="pharmacovigilance">
                    </div>
                </div>
            </div>
        </div>
    </form>
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