About you

Please answer the following questions about yourself (or for the person who will take this medicine). If you get stuck or need any help, use our CHAT button below or give us a Call on 01639 502860

What is your age (or the person who will take this medication)?

Do you have any medical conditions or previous surgeries?

If yes please provide more details

Yes

If you are not the person who will use this medication, please enter their details here (only with their full consent)

Please describe in detail who the intended user is and answer all questions on their behalf

What is your biological gender?

Please select your option

Male

Female

Transmale (Born a female)

Transfemale (Born a male)

If female or transmale: Are you pregnant, planning pregnancy, or is there any possibility that you could be pregnant?

Yes

Do you have any liver or kidney problems?
If yes, please provide details

Yes

Do you have diabetes?

If yes is this Type I or II?

Yes

Do you have cardiovascular (heart) conditions or have had a stroke?

If yes please provide more details

Yes

Is your immune system suppressed due to disease or treatment?
If yes please provide more details

Yes

Please provide more information about your living and work conditions
e.g. I live with 2 people and a cat, am a painter and decorator

Do you take any medicines?

Please list all your current prescription medication, medicines you buy including any herbal medicines and recreational drugs if taken.

Yes

Do you drink alcohol?
If Yes please provide more details on how many units per week and usually when consumed

Yes

Do you currently feel severely unwell?
If yes please provide more details

Yes

Are you a smoker or an ex-smoker?
If yes please provide more details

Yes

Do you have any allergies?

If yes please provide more details

Yes

About your Condition and Health

Please answer the following questions to help us understand more about your symptoms and health

What Ear symptoms are you (or the person that will use this medicine) currently experiencing
Please select as many symptoms needed

Itching/ irritation

In the ear canal there is pain or discomfort

An ear canal discharge that is watery

The skin surrounding the exterior of the ear and around the canal is dry and flaking

Due to swelling and inflammation the ear canal becomes obstructed

Hearing impairment in the affected ear

How long have you (or the person who will use this medication) experienced these symptoms?

Please select your option

A week

A month

More than a month

Less than 1 day

1-2 days

More than 3 days

Have you (or the person who will use this medication) tried a different medicine to treat the symptoms before?

If yes, what medicine was it and was it effective ?

Yes

Do your symptoms only affect one ear?

Yes

Does pulling the middle of your earlobe toward the back of your head aggravate the pain?

Yes

Are you using Otomize to treat a recurrence of a swimmer's ear infection that was previously diagnosed?

Yes

Do any of the following apply to you or the person that will use this medication?

You've had cholesteatoma (an abnormal growth of skin in the middle ear beneath the eardrum) from birth or as a result of repeated ear infections.
You've experienced ear difficulties in the past that necessitated a visit to an ear, nose, and throat specialist.
You have facial nerve palsy and suffer pain in your jaw when chewing or speaking (drooping face on the side of the lesion)
You have a fever of more than 39°C, you are physically ill, and you have vertigo.
You suffer from severe hearing loss.
You have an infection that has migrated beyond your ear.

Yes

Do you have a history of experiencing:

Ear infections that last a long time.
Ear infections caused by fungi.
Wax in your ears that needs to be removed with drops or ear syringing

Yes

Have you had a serious reaction or side effects to neomycin sulfate, dexamethasone, glacial acetic acid or any ingredients of Otomize before?

If yes, please describe the product and the reaction

Yes

Do you have a perforated ear drum or grommet fitted in the affected ear?

Yes

Do you have an infection anywhere other than in the ear?

Yes

Do you have any open wounds or damaged skin in the affected ear?

Yes

Have you experienced a considerable amount of discharge from your ear or swelling of the ear canal?

Yes

Have you had persistent infection for the last 3 months?

Yes

Our Prescribing Contract

Please confirm your agreement to our prescribing partnership

Do you agree to the following?

You will read the patient information leaflet supplied with your medication. The treatment is solely for your use (or the person you have completed this for and with their consent). You have answered all the above questions accurately and truthfully. You understand our prescribers take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health.

Yes

Can we share this information with your General practitioner?

We advise you to share this treatment with your doctor so they can update your medical records. Please provide their address if appropriate.

Yes

Do you agree to tell your doctor or pharmacist about any side effects you may be experiencing with the medicines and any progression of symptoms?

Yes

Do you agree you will contact us and inform your GP if you start new medication or if your medical conditions change during treatment?

Yes

Is there anything else we need to know that is relevant to this consultation?

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