About Your Health
To help us understand that this treatment is the right option for you, please answer the following questions. If you get stuck or need any help, you can contact us.
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Are you the actual consumer of this medicine?
If not, please describe in detail who the intended consumer is and how old he/she is.
Do you relate to the following?
You are allergic or hypersensitive to Scopoderm.
Are you on any of the following treatments?
Antihistamines.
Do you experience any of the following problems?
Stomach conditions like Pyloric stenosis.
Do you have a history of using Scopoderm patches to treat your travel illness in the past?
If you do, how successful were they?
Do you consent to seeking further medical guidance in the following instances?
Acute and unexpected abdominal pains.
Are you experiencing any of the following signs and symptoms?
Constant vomiting for more than 48 hours?
Once you get home from travelling, do your symptoms last for more than one day?
Do you require assistance?
Is there a need for you to take motion sickness medication frequently?
Do you require assistance?
Have you experienced travel sickness for a long time or have you just experienced it recently?
Please select your option
Can you relate to any of the following?
You have an underlying medical condition
Are you currently receiving any treatment or under any medication?
Please provide more information of the medication being used if any.
If female or transmale, are you currently pregnant, breastfeeding or planning to do so?
Please select your option
What is your biological gender?
Please select your option
Date of Birth
Use the calendar to select your date of birth.
Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month January February March April May June July August September October November December Year 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924
Can we share this information with your General practitioner?
Providing us with your physician's address means that you allow us to share this information with him/her for updated medical records if need be. It also allows our clinician to access your medical records if there is a need for that. We advise you share this treatment with your doctor for him/her to update your medical records.
Has the target user tried a different medicine to address the symptoms before?
If yes, what medicine was consumed and how effective was it?
For how long has the consumer of this medicine experienced these symptoms?
Please select your option
What symptoms do you intend to treat using this medicine?
Please provide more information
Can you relate to any of the following??
You have an underlying medical condition
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