1. About your Health
Your health and safety are our top priorities. To ensure we provide you with the most effective and appropriate treatment, it is crucial that you provide accurate and complete information about your health during our online consultation process. Accurate information helps us understand your condition better, assess any potential risks, and recommend the best possible medication for your needs. Providing false or incomplete information can lead to inappropriate treatment, potential health risks, and delays in receiving the care you need. Thank you for your cooperation and trust in our services.
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Can we share this information with your General practitioner?
What is your Date of Birth?
Please use the following format 00/00/0000
For how long has the consumer of this medicing experienced these symptoms?
Has the target user tried a different medicine to address the symptoms before?
Do you have any known allergies?
If yes, please list them.
Do you have any chronic conditions? (e.g., diabetes, hypertension, asthma, etc.)
If yes, please list them:
If female or transmale, are you currently pregnant, breastfeeding or planning to do so?
Have you had any surgeries in the past year?
If yes, please provide details:
Are you currently receiving any treatment or under any medication?
Can you relate to any of the following?
Do you consume alcohol?
If yes, how often?
Does your problem only affect one ear?
Which signs and symptoms are you currently experiencing?
Does pulling the middle of your earlobe toward the back of your head aggravates the pain?
Are you using Otomize to treat a recurrence of a swimmer's ear infection that was previously diagnosed?
Do you have a history of experiencing:
Do you recognize yourself in any of the following scenarios:
Are you presently experiencing:
Do you know of any ingredients in Otomize that you are allergic to or sensitive to?
Did you know that:
What symptoms do you intend to treat using this medicine?
Are you the actual consumer of this medicine?
Do you currently have an infection of the outer ear?
Women only: Are you pregnant, planning pregnancy, or is there any possibility that you could be pregnant?
Women only: Are you breast feeding?
Do you have a perforated ear drum or grommet fitted in the affected ear?
Have you had a serious reaction or intolerable side effects to neomycin sulfate, dexamethasone, glacial acetic acid or any medications before?
Are you immunosuppressed due to disease or treatment?
Do you have any liver or kidney problems?
Are you suffering from severe pain or discomfort?
Do you have any allergies?
Do you have an infection anywhere other than in the ear?
Do you have any open wounds or damaged skin in the affected ear?
Have you experienced a considerable amount of discharge from your ear or swelling of the ear canal?
Have you had persistent infection for the last 3 months?
Please list all your current prescription medication including any medication you buy over the counter...
Please provide details of any recent or past medical history of note
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2. About your Condition
Accurately describing your condition during our online consultation is essential for ensuring you receive the best possible care. Detailed and truthful information about your symptoms, their frequency, and their severity allows our healthcare professionals to make informed decisions about your treatment. Incomplete or incorrect descriptions can result in inappropriate medication, potential health risks, and delays in your care. Your honesty and thoroughness help us provide you with the most effective and safe treatment options. Thank you for your cooperation and trust in our services.
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How long have you been experiencing symptoms of an ear infection?
What symptoms are you currently experiencing? (e.g., ear pain, discharge from the ear, hearing loss, fever, itching, dizziness)
Are your symptoms affecting one ear or both ears?
Have you been diagnosed with an ear infection by a healthcare professional?
Have you had any tests to confirm the diagnosis? (e.g., ear examination, hearing test)
If yes, please provide details:
Have you identified any possible triggers or causes for your ear infection? (e.g., recent cold or respiratory infection, water exposure, allergies)
Have you been prescribed medication for an ear infection before?
If yes, please list the medications:
Are you currently taking any medication for your ear infection?
If yes, please provide the name and dosage:
Have you experienced any side effects from your current or past ear infection medications?
If yes, please describe:
Have you tried any non-medication treatments for your ear infection? (e.g., warm compresses, keeping the ear dry)
If yes, please describe:
Have you used over-the-counter treatments for ear infections?
If yes, which ones and were they effective?
Do you agree to the following?
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