Male Patients Form 8

YES If NO, I DO NOT, please specify:

LESS THAN 12 MONTHS MORE THAN 12 MONTHS

LESS THAN 12 MONTHS AGO MORE THAN 12 MONTHS AGO

NO If YES, I WAS, please specify:

NO If YES I HAVE, please specify:

MALE FEMALE

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

I CONFIRM