Name
*
First Name
Last Name
Gender
*
Male
Female
Date Of Birth
*
MM
DD
YYYY
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email
*
Phone
*
(###)
###
####
Please tell us about your symptoms so we can recommend the right treatment for you.
*
What symptoms are you currently experiencing?
When did your symptoms start this year?
*
Are your symptoms worse during certain seasons or around pets/dust/mould?
*
Are your symptoms affecting your sleep or daily activities?
*
Yes
No
Please describe your symptoms in your own words
*
Have you used hay fever treatments in the past?
*
Yes
No
If yes, which treatments have you tried (e.g., loratadine, cetirizine, beclomethasone nasal spray)?
Did these treatments help control your symptoms?
*
Yes
No
Are you currently taking anything for hay fever?
*
Yes
No
Please list what you’re currently using
These questions screen for potential risks before prescribing medications like antihistamines, nasal sprays, or steroid treatments.
*
Do you have any of the following? (Check all that apply)
Are you pregnant or breastfeeding?
*
Yes
No
Not Applicable
Do you have asthma or other breathing conditions?
*
Yes
No
Do you take any regular medications (including over-the-counter)?
*
Yes
No
If yes, please list them
Do you have any known allergies to medications (e.g., antihistamines, steroids)?
*
Yes
No
If yes, please specify
Do you suffer from other allergies (e.g., to food, animals, dust, pollen)?
*
Yes
No
Have you ever experienced severe allergic reactions (anaphylaxis)?
*
Yes
No
Have you used steroid tablets or injections for hay fever in the past?
*
Yes
No
Do your symptoms occur year-round or only seasonally?
*
Seasonally
All-year round
Consent & Declaration
*
