Question 1 of 3

Have you previously been diagnosed with hay-fever (seasonal allergic rhinitis) or suffered any hay-fever-like symptoms such as:

• Itchy or red eyes, Runny or blocked nose, Frequent sneezing?

Question 2 of 3

Have you experienced any of the following symptoms in the past or been diagnosed with the following?

• Visual disturbances, Dry mouth, Urinary retention, Chronic constipation
• Impaired kidney or liver function, Angle-closure Glaucoma, Pyloroduodenal obstruction
• History of heart problems such as an irregular heartbeat (arrhythmia) , palpitations or angin

Question 3 of 3

Are you currently taking any of the following medications?

• Alpha-blockers such as, Tamsulosin, Terazosin, Doxazosin
• Erythromicin or Ketoconazole
• Medication to treat Glaucoma
• Anticholinergic medication  such as Tolterodine, Solifenacin, Trospium