Ear Infection

About your condition and treatment

To help us understand that this treatment is the right option for you, please answer the following questions. If you get stuck or need any help, you can contact us.

What age are you (or the person who will use this medication)?

Do you have any cardiovascular conditions or have you suffered a stroke

Yes

Are you female?

Please select any conditions that apply

Presently Pregnant

Presently Breastfeeding

Planning on getting pregnant

Neither Pregnant nor Breastfeeding

What is your biological gender?

Please select your option

Male

Female

Prefer not to say

Have you (or the person who will use this medication) any medical conditions or previous surgeries?

Please provide more information of the medication being used if any.

Yes

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

What symptoms do you intend to treat using this medicine?
Please provide more information

If you are not the person who will use this medication, please enter their details here

If not describe in detail who the intended consumer is and how old he/she is.

Yes

Do you have diabetes?

Yes

Women only: Are you pregnant, planning pregnancy, or is there any possibility that you could be pregnant?

Yes

Please provide details of any recent or past medical history of note

Women only: Are you breast feeding?

Yes

Are you immunosuppressed due to disease or treatment?

Yes

Please list all your current prescription medication including any medication you buy over the counter...

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

Yes

Are you suffering from severe pain or discomfort?

Yes

Do you have any allergies?

If yes, please provide details - include medicines, food, materials or anything else

Yes

Our Agreement

Please answer the following questions to help us confirm that you'll follow the guidelines for this medicine.

Do you currently have an infection of the outer ear?

Yes

Which signs and symptoms are you (or the person who will use this medication) currently experiencing?
You can select more than one option

Itching

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

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

Does your problem 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 you recognise yourself in any of the following scenarios:

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. You have a large amount of ear discharge.

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

Are you presently experiencing:

A grommet was installed. An eardrum that has been perforated (tympanic membrane) Dysfunction of the kidneys or the liver

Yes

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

Yes

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

If yes, please describe the product and the reaction

Yes

Do you know of any ingredients in Otomize that you are allergic to or sensitive to?

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

Do you agree to the following?

You will read the patient information leaflet supplied with your medication
You will contact us and inform your GP of your medication if you experience any side effects of treatment, if you start new medication or if your medical conditions change during treatment.
The treatment is solely for your own use
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

Risk Assessment

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

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