Female Patients Form 8

LESS THAN 12 MONTHS MORE THAN 12 MONTHS

YES If NO, I DO NOT, please specify:

MALE FEMALE

NO If YES, I WAS, please specify:

NO If YES, I WAS, please specify:

LESS THAN 12 MONTHS AGO MORE THAN 12 MONTHS AGO

NONE VENTOLIN INHALER GERIVENT INHALER SALAMOL INHALER SALBUTAMOL INHALER ALBUL INHALER BRICANYL TURBOHALER SALAMOL EASIBREATHE VENTOLIN DISKUS If OTHER, please specify:

I CONFIRM