General Health

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.

Yes

No

On which part of the body will this product be used?

For which duration has the consumer of this medicing experienced these symptoms?
Hello

Can you relate to any of the following?
You have an underlying medical condition
You've been through a major surgical procedure
You have allergic reactions
You have cardiovascular conditions or might have had suffered a stroke
You suffer from a low liver or kidney function

Yes

No

Can you relate to any of the following?

Your hair loss started recently, and you've lost a lot of hair in less than four weeks.

Hair loss has occurred in irregular spots on your head.

Your scalp is itchy or inflamed.

You've lost your hair as a result of your pharmacological treatment.

You're completely bald or have lost all of your body hair.

Yes

No

What is your biological gender?
Please select your option

Male

Female

Transmale (Born a female)

Transfemale (Born a male)

Has the target user tried a different medicine to address the symptoms before?
If yes, what medicine was consumed and how effective was it?

Yes

No

Can you relate to the following?
You have an underlying medical condition
You've been through a major surgical procedure
You have allergic reactions
You have a cardiovascular condition or have suffered a stroke
You suffer from a low liver or kidney function

Yes

No

Are you currently receiving any treatment or under any medication?
Please provide more information of the medication being used if any.

Yes

No

If female or transmale, are you currently pregnant, breastfeeding or planning to do so?
Please select your option

Presently Pregnant

Presently Breastfeeding

Planning on getting pregnant

Neither Pregnant nor Breastfeeding

What's your gender?

Male

Female

Transmale (Born a female)

Transfemale (Born a male)

Are you aware that we can only provide one pseudoephendrine product per order?
Pseudoephedrine is found in over-the-counter drugs such as:
Combo of Actifed Day and Night Nurses
Sudafed Sinus Pressure & Pain pills and Sudafed Sinus Pressure & Pain tablets
Multiple items from this list will be retained and refunded in one order.

Yes

No

For how long has the consumer of this medicing experienced these symptoms?
Please select your option

At least 72 hours

A week

A month

More than a month

What symptoms do you intend to treat using this medicine?
Please provide more information

Are you experiencing any of the following problems?

Anaemia.

Deficiency in glucose-6-phosphate dehydrogenase.

Methaemoglobinaemia.

Atopic dermatitis - a type of dermatitis that affects the skin.

Yes

No

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