SensiStop Full Remedy Pack

 

Please answer as many as possible of the questions below.

Patient Name
Date of Birth (dd/mm/yy)
When was the Allergy diagnosed?
By whom?	-SELECT- GP Specialist
What kind of allergic symptoms do you have?
Current treatment/Drug name
When was this treatment started?
Has this drug relieved your symptoms?	-SELECT- No Slightly Moderately Very much
Which other drugs have you tried before (if any)?
For how long did you try other drugs (if any)?

Thank you for your kind co-operation.