DAY NURSE CAP 20S

1. Who will use this medicine ?

Myself

Other

2. What is the gender of the person using this medication ?

Male

Female

Other

- Is the person pregnant or breastfeeding ?

None

Yes

No

I don't know

4. What are the symptoms being treated ?

5. How long have these symptoms been present ?

6. What other medicines have been tried to treat the symptoms ?

7. Does the intended user have any existing medical conditions ?

Yes

No

- What medical conditions does the person have ?

8. Is the intended user currently on another medication ?

Yes

No

- What medication is the person taking ?

9. Does the intended user have any known allergies ?

Yes

No

- Please specify all allergies :

10. Please provide any other relevant information :

Company