Show with the stuffy nose! Get a FREE personal allergy profile for more allergy relief! Do you have 1 SEASONAL Check all of the allergy-relate- Which of the following activities do you participate in on a regular basis? (check all that apply) 6 symptoms you d experience: ALLERGIES (a) Would you like to know (e) more about managing them so you can feel (g) Z Runny (h) nose Li Sneezing itchy nose Hives or itchy skin (d) (f) (i) Z L Zl CampingHiking (e) Gardening (f) L Itchy palate or ears (i) Horseback Riding Scuba Diving Swimming (j) Z (g) Z (k) pi) Z Z Bicycling and this survey take the first step to more relief Fly (c) 3 to answer these survey questions over the phone Rate the severity of your allergy symptoms on a scale of 1 to 10 with 1 being mild and 10 being severe: (b) (a) 4 (f) (g) (h) (I) severe Z Yes (b) Z No Offer expires Managerial (c) (d) Z Craftsman Machine Operator Student (e) Not Employed 0 Z Z 13199 (b) allergy treatment Visited a doctor for another reason and (c) (d) n 3 asked about seasonal allergy treatment Visited a doctor but did not ask about seasonal allergy treatment Have not seen a doctor (a) Z (b) Z j (e) CRN070422088505 898 Z ClericalService Sales FarmerRancher Homemaker Retired Other Z Spouse Child over 12 Child 12 and under Other No one else suffers from allergies n p rn First Name Zi W CjjzJuIjjIQj lUZE ILGLIjLZjujJL Last Name Street Name Street Number SuiteApt Copyright © 1998 Schering Corporation Kenilworth NJ 07033 All rights reserved Z 10 Other than yourself do any of the following members of your household suffer from allergies? months? Visited a doctor specifically for seasonal (f) Z Which of the following have you done in the last 12 (a) No (b) (d) information Z Professional (c) receive any additional (d) 9 Do you have any children age 12 and under? No Yes (b) (a) 02185 5 No Z (i) yes what is your primary brand of prescription allergy medication? Check here if you do not want to Z (a) (g) If MA (b) frequently? Z Yes (j) Have you used a prescription allergy medication in the last 12 months? (a) 859066 Braintree (e) mild Schering Personal Allergy Profile Box (d) 10 weeks Mail this survey to: P0 (c) ZZZZULLZZZ 123456789 FREE fully customized profile 3 Z RunningJogging Snow Skiing Tennis What is your occupation? (please check only one) 8 call 2-- (I) Golf 7 Does your occupation require you to: Drive frequently? Yes (a) in (h) Z Z BoatingSailing Fishing Walking for Health Take a quick moment to complete and return receive your Z Z (c) out of every day? You’ll Z (d) (a) better and get the most Or (b ) nose Sinus pain Scratchy or sore throat Z Stuffy (b) Itchywatery eyes (c) Number City State ZIP Code 1309 |