About your condition and treatment
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.
0%
Back
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.
For how long has the consumer of this medicine experienced these symptoms?
Please select your option
Has the target user tried a different medicine to address the symptoms before?
If yes, what medicine was consumed and how effective was it?
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
Please add your current weight (in kgs).
Please make sure to add your current weight. This may affect the prescriber's decision.
If female or transmale, are you currently pregnant, breastfeeding or planning to do so?
Please select your option
Are you currently receiving any treatment or under any medication?
Please provide more information of the medication being used if any.
Can you relate to any of the following?
You have an underlying medical condition
Does your problem only affect one ear?
Which signs and symptoms are you currently experiencing?
You can select more than one option
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:
Ear infections that last a long time.
Do you recognize yourself in any of the following scenarios:
You've had cholesteatoma (an abnormal growth of skin in the middle ear beneath the eardrum) from birth or as a result of repeated ear infections.
Are you presently experiencing:
A grommet was installed.
Do you know of any ingredients in Otomize that you are allergic to or sensitive to?
Did you know that:
A healthcare practitioner should assess any acute injuries.
What symptoms do you intend to treat using this medicine?
Please provide more information
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 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?
If yes, please describe the product and the reaction
Are you immunosuppressed due to disease or treatment?
Do you have any liver or kidney problems?
If yes, please provide details
Are you suffering from severe pain or discomfort?
Do you have any allergies?
If yes, please provide details
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?
Do you currently take any medication whatsoever?
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
Next
