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Customer Medical Questionnaire – Clotrimazole 1% Cream Treatment

Please answer every question so we can check this treatment is suitable. Your answers are used only to decide whether the medicine can be supplied, are reviewed by a pharmacist where needed, and are deleted after a fixed retention period.

eBay order number

*

1. Who is the treatment for?

*

A

Myself

B

Someone else

2. Age of the person needing treatment

*

A

16–60

B

Under 16

C

Over 60

3. What condition is this medicine being used for?

*

A

Ringworm

B

Athlete’s Foot

C

Fungal Nappy Rash

D

Fungal Sweat Rash

E

Thrush Vaginal/Penile

4. Do any of the following apply to the intended user?

*

Select all that apply.

Allergic to clotrimazole or any of the other ingredients

Currently pregnant or breastfeeding

High temperature

Severe pain in the area

Signs of sepsis

None of the above

7. Do you agree to read the Patient Information Leaflet and use the medicine as directed?

*

A

Yes

B

No

Use of your answers

*

I agree to my answers being used to decide whether this medicine can be supplied and being reviewed by a pharmacist.

I agree