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FAQ

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Claritin

Claritin is classified as an antihistamine, generic name Loratadine. 

Claritin is indicated for the treatment for seasonal allergic rhinitis, or idiopathic/chronic urticaria. 

[default to personal information, name, address, etc. as with all the other consultations]

Medical History

Please indicate on this form your current medical history and be as accurate as possible:

Sex  (male or female)

Height:

Current Weight:

Date of Birth:

Do you smoke?  (yes or no)

Do you consume more than two alcoholic beverages per day?  (yes or no)

Current medication conditions and past medical history:

Are you allergic to any prescription medication?

Do you have or have you ever had any of following medical problems, such as:

            Coronary Artery Disease

            Congestive Heart Failure

            Heart Disease of any kind

            Multiple Myeloma

            Diabetes

            Low Testosterone

            Liver Disease

            Depression

            Spinal Cord Injuries

            Leukemia

            Sickle Cell Anemia

            Low or High Blood Pressure

            Schizophrenia

            Stroke

            Arteriosclerosis

            Enlarged Prostate

            Hypertension

            Peyronie’s Disease

            Congestive Heart Failure

            Any Anatomic Deformations of the Penis

            Obesity

            Prostate Disease

            Thyroid Disease

            Kidney Disease

            Anxiety

            Endocrine Disorders

            Retinitis Pigmentosa

Are you currently taking any medications?  If so, please list them:

            [this should be the similar history for all medications]

Are you nursing or pregnant? (yes or no)

Do you have high blood pressure?  (yes or no)

Have you ever had a heart attack?  (yes or no)

Do you have asthma?  (yes or no)

Do you suffer from year-round or seasonal runny or itchy nose, watery eyes, sneezing or hives?  (yes or no)

Are you allergic to any substance, such as: foods, medications, pollens, etc.?  (yes or no)

If yes, please specify:

Precautions should be taking in anyone using the medicine Claritin who has hepatic or renal dysfunction, meaning liver or kidney dysfunction, or any mothers who may be nursing. 

Adverse reactions can include, but are not limited to: headache, somnolence, fatigue, dry mouth, nervousness, wheezing, hyperkinesia, abdominal pain, conjunctivitis, dysphonia, malaise, bronchospasm, and/or upper respiratory infections in children.  I understand and am aware of the risks and precautions with taking this prescription medication, and I certify that I am currently not receiving this medication from any other physician, and that I will inform any and all physicians involved in my care that I am taking this prescription medication.

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