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Who is the medicine for?
What is the age of the person using this medicine? ( If more than one person please include the age(s) of the youngest and oldest )
What are the symptoms that you are using this medicine for and how long have you experienced them?
Please state if you have any existing medical conditions e.g asthma , diabetes high blood pressure
Are you taking any other medication (including herbal products and vitamins) that have been prescribed or purchased ?
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