Travel Sickness

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

Do you relate to the following?
You are allergic or hypersensitive to Scopoderm.
You've have a history of using hyoscine and suffered negative side effects.
You are already using the treatment to manage a different condition from travel illness
Glaucoma is a condition that you have.

Yes

No

Are you on any of the following treatments?
Antihistamines.
Antidepressant.
Amantadine.
Quinidine.
Alkaloids

Yes

No

Do you experience any of the following problems?
Stomach conditions like Pyloric stenosis.
A hinderance in your bladder that makes it difficult or uncomforatable to urinate.
An obstruction in the intestines.
Epilepsy.
Straining of the eye that causes pain, vision impairement among others.

Yes

No

Do you have a history of using Scopoderm patches to treat your travel illness in the past?
If you do, how successful were they?

Yes

No

Do you consent to seeking further medical guidance in the following instances?
Acute and unexpected abdominal pains.

Intolerable chest pains.

Visible blood when you throw up

High fever and an inflexible neck.

Acute headache.

Yes

No

Are you experiencing any of the following signs and symptoms?
Constant vomiting for more than 48 hours?
Vomiting so much that your body is unable to hold any liquids down?
Green vomit that serves as an indication of bowel blockage?
Confusion, a quick heartbeat, sunken eyes, and producing little to no urine?
Quickly or unplanned weightloss?
high fever, body chills, migranes, or diarrhoea?
Do you require assistance?

Yes

No

Once you get home from travelling, do your symptoms last for more than one day?
Do you require assistance?

Yes

No

Is there a need for you to take motion sickness medication frequently?
Do you require assistance?

Yes

No

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
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

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 is your biological gender?
Please select your option

Male

Female

Transmale (Born a female)

Transfemale (Born a male)

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

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

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

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

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