Order Sea and Motion Sickness Treatment (Patient assessment form)

Have you used any motion sickness medication before (either prescription or non-prescription medication)? *

YesNo

If yes, what medications have you used before for motion sickness?

Have you experienced undesired side effects such as drowsiness from motion sickness medication you have used in the past or have you found the medication to be ineffective for you?

YesNo

Have you used medication supplied by our pharmacy for motion sickness before? *

YesNo

If you selected ‘Others’ or ‘Self & Others’ please detail the individuals who will be using this medication*

If you selected ‘Under 18’ please tell us the ages of any individual below 18*

Is any person requiring treatment currently using any other medication? *

YesNo

Is any person requiring treatment suffering from any medical conditions? *

YesNo

Contact Details*

Address Line 1: Address Line 2: City: State: Postcode: Country: Email Address *: Phone Number *: