Which antibiotic do you use to take? Ampicillin □ Amoxicillin □ Ciprofloxacin □ Cotrimoxazole □ Erythromycin □ Metronidazole □ Doxycycline □ Other (write the name): ………………….…………………………………………………………………

Who prescribed this antibiotic for you? ……………………………………………………………

How long have you been taking it? ………………………………… (days, months, years)

How often do you take it? Usually □ Often □ Rarely □ If needed □ For which disease?:……………………………………………………………………………………………

Are you taking this antibiotic during your hospitalization? Yes □ No □