Insomnia

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

What are you treating with Sominex?

Does any of these describe you?
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

Since when have you struggled with heartburn/acid reflux?

It's my first time

Under a month

Almost a year

Several years

After taking naproxen for Gastric Protection

What's your gender?

Male

Female

Transmale (Born a female)

Transfemale (Born a male)

Does any of the following statements apply to you:
Orlistat causes an allergic reaction or hypersensitivity in you.
You've previously used Orlistat and experienced serious side effects.
You are experiencing rectal bleeding.
You have chronic malabsorption syndrome, which has been identified by a doctor.
You have been diagnosed with cholestasis (condition where the flow of bile from the liver is blocked)

Yes

No

Are you aware of the following:
It is never a good idea to self-diagnose and treat urine incontinence.
At the very least, you should see your doctor for a checkup once a year.
You must follow your doctor's instructions for any treatment.
You should only order repeat supplies of medicines that your doctor has prescribed.

Yes

No

Are you using any of these medications:
Mono Amine Oxidase Inhibitors
Irritable bowel syndrome, asthma, and a weak bladder medications.
Seizure medications
Strong analgesics (e.g. codeine, morphine or buprenorphine).
Antidepressant medications (such as amitriptyline).
Medications for the treatment of mental illnesses (such as promazine, flupentixol or haloperidol).
Medicines that make you sleep better or make you feel more relaxed (such as diazepam or zolpidem).
Aspirin and other pain relievers (for arthritis and pain in your joints).
Isocarboxazid \sPhenelzine

Yes

No

Have you ever consulted your doctor about these symptoms?

Yes

No

For how long have you been dealing with these issues?
Please select one option

At most seven days

Between a week to a month

Around two weeks

Please inform us about the possible causes of these signs and symptoms.

What are you treating with Nytol?

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 advice you share this treatment with your doctor for him/her to update your medical records.

Yes

No

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