1. Have you read information about your symptoms on Patient.info?

Yes

No

2. Which of the following hay fever symptoms do you experience? Please tick all that apply.

3. Please specify any other symptoms you are experiencing

4. Have you had recurrent nose bleeds, blood stained or green discharge, pain OR discharge from your nose?

Yes

No

5. If you answered yes, please give more details:

6. Have you ever used antihistamine tablets for your hayfever?

Yes

No

7. Have you ever used steroid nasal spray for your hayfever?

Yes

No

8. If you answered yes, which steroid nasal spray did you use?

Yes

No

9. If you answered yes, how long did you take it for?

10. If you answered yes, did you find the steroid nasal spray beneficial?

11. If you answered yes, please specify which ones:

12. If you answered yes, please specify any side-effects you have experienced from them:

13. Are you aware that you should do regular steam inhalation for your hayfever?

Yes

No

14. Are you aware that you should do regular nasal lavage (washing the insides of the nose with warm water) for control of your hayfever symptoms?

Yes

No

15. Are you aware that you need to use nasal sprays for at least 3-6 months for control of your symptoms?

Yes

No

16. Do all of the following apply to you?

• I will read the patient information leaflet supplied with my medication.
• The medication is for my own use. (Partners, spouses etc must log out, complete their own consultation and register separately)

Yes

No