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Hayfever

To ensure you are provided with the most effective treatment by our healthcare professional please answer the questions honestly and accurately. The questionnaire should only take approximately 3 minutes to complete.

If you are unsure about any of the questions, please call us on 0115 8501944 or email us at [email protected]

1. Hi. What is your name?

2. Are you purchasing this medication for yourself?

3. Are you over 18?

4. Are you breast feeding or pregnant or planning to become pregnant

4b. Please provide more information.

5. Do you smoke?

5b. Would you like information on stopping smoking?

6. Do you drink alcohol?

6b. Would you like information on safe alcohol use?

7. Are you overweight?

7b. Would you like information on weight management?

8. Are you suffering with allergic rhinitis or hayfever?

9. Are you experiencing any of the following?

10. Is this allergic rhinitis / hayfever symptoms different to what you have experienced before?

10b. Please provide more information

11. Have you tried any other allergic rhinits / hayfever treatments before?

11b. Please provide more information about what was used and its treatment response

12. Are you suffering from any of the following?

13. Do you have any kidney or liver impairment?

14. Do you have any other medical conditions (e.g. cancer) or past surgical procedures (e.g. splenectomy)?

14b. Please provide more details:

15. Are you currently taking or recently stopped taking any prescription medicines, over-the-counter medicines, herbal medicines or recreational drugs?

15b. Please provide more details:

16. Are you allergic to any medicines or other substances e.g. peanuts or soya?

16b. Please provide more details:

17. Would you like us to pass on details of your treatment to your GP?

18. Do you agree with the following?

We cannot supply you with this treatment at this moment. Please contact our patient support team at [email protected] so we can talk through your options.

  • You have read the information available on the treatments and medication web page and understand the side effects, their effectiveness and alternatives available.
  • I will contact my GP if I experience no relief after 14 days or your symptoms persist after 28 days of treatment.
  • You have answered the questions honestly and accurately and the treatment is solely for your personal use.
  • You will read and understand the patient information leaflet supplied with your medication.
  • You understand that although it is not compulsory it is important to inform your GP of this treatment so they can provide safe healthcare.
  • You understand prescribing decisions will be based on the answers from your consultation and incorrect information can cause harm to your health. Orders may be rejected if not clinically suitable.
  • You are aware The Family Chemist will undertake a soft check to validate your identity using LexisNexis. Note: This does not affect your credit rating.
  • You have read and agree to our Terms and Conditions, Terms of Use and Privacy Policy.

19. I confirm that I have read the information in this questionnaire and will follow the advice from the patient information leaflet before using the provided treatments.

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