AlivePlusPharmacy - Pharmacist Product Questionnaire

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Pharmacist Questions

You have added: Glytrin Antianginal 400mcg/dose PumpSprays (250 doses) to your shopping cart.

This a "Pharmacist Only" medicine. To comply with the requirements of the New Zealand Medicines Act we need to ask you the following questions to ensure this is the correct medicine for your needs. Our pharmacist will review your answers and may contact you via email to seek further information, if required. Please fill in all the fields below.

Please provide answers to the required fields (marked with a red astrisk).

* Who is this treatment for and how old are they?

* Please describe your symptoms?

* How long have they been present? Have you experienced these symptoms before? If yes, when was the last occurance?

* What treatment (if any) has been tried already?

* Have they used this product before? If yes, was it effective?

*What other medication are you taking, if any?
Please include prescribed or purchased medication and alternative therapies.

*Are you asthmatic?

*Do you suffer from stomach problems?

*Do you have any other health conditions or allergies, including pregnancy/breastfeeding?

*Has a Health Professional recommended that you use this product on this occasion?
If not, has a doctor previously diagnosed this condition and are the symptoms the same as the previous diagnosis?

*Is there any other information you feel we need to know? Do you have any other questions you would like answered?

* I agree to use it strictly as directed and if symptoms persist or if I suffer any adverse effect I will contact my doctor or pharmacist immediately.

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