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Zyrtec Consultation
Do you suffer from any of the following conditions: hayfever (including sneezing, nasal discharge, itching nose or eyes), itchy skin due to allergies, or hives?:	Yes No

Are you pregnant, breastfeeding, or planning to become pregnant in the near future?:	Yes No

Have you ever experienced any unusual or allergic reaction to Zyrtec (Cetirizine) or Atarax (Hydroxyzine)?:	Yes No

Do you suffer from any form of kidney disease or dysfunction?:	Yes No

Do you suffer from any other medical conditions? If so, please give details.:

Do you take any other medicines? If so, please list all prescription and non-prescription medicines you are currently taking:

  •  Allegra 180mg
  •  Allegra 60mg
  •  Beconase 50 mcg N...
  •  Berocca
  •  Celebrex 100mg
  •  Celebrex 200mg
  •  Claritin (Claratyne)
  •  Flonase
  •  Fosamax 10mg
  •  Fosamax 70mg
  •  Hoodia Weightloss
  •  Imedeen
  •  Lipitor 10mg
  •  Lora-tabs (generi...
  •  Nicorette
  •  Nizoral Cream 2%
  •  Nizoral Shampoo 2%
  •  Omega 3 1000mg
  •  Prevacid 30mg (Z...
  •  Propecia
  •  Rogaine 5
  •  Voltaren Gel
  •  Xenical
  •  Zetia (Ezetrol) 10mg
  •  Zocor (Lipex) 10mg
  •  Zocor (Lipex) 20mg
  •  Zocor (Lipex) 40mg
  •  Zovirax Cream
  •  Zyrtec

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