Dose the patient being treated have any of the following conditions?

• Over 70 years old and frail.

• Less than 8 years of age.

• Fever over 101.5 F.

• Symptoms that have gotten worse or new symptoms have occurred after self treating with OTC medications.

• Respiratory or cardiovascular conditions including asthma, COPD, or congestive heart failure.

• Chest pain or shortness of breathe.

• Immunosuppression (are on medications that suppress the immune system or have a health conditions that suppresses the immune system).

• AIDS.

• Having any of the following symptoms, and have never been diagnosed with a migraine: Nausea, headache on only one side of the head, visual changes such as seeing lines or changes in light before the onset of the headache, numbness or tingling before the onset of the headache, trouble speaking before the onset of the headache, worsened mood after the headache, depression after the headache, fatigue after the headache, and difficulty solving problems after the headache.

• Allergy to OTC medications.

• Cough that has lasted more than seven days.

• Using over the counter drugs for headache treatment more than three days per week.

• Cough produces yellow, tan or green mucus or is secreting pus.

• Cough is a side effect from a drug such as lisinopril.

• Cough is from inhaling irritants or foreign material into the lungs.

• Cough is accompanied by chills, night sweats, weight loss, rash, swollen ankles or legs.

• Severe head pain.

• Headache has persisted for more then 10 days.

• Pregnancy.

• Are taking drugs known as MAOI inhibitors or have taken them within the last 14 days. MAOI's include the following drugs: Zelapar (selegiline), Nardil (phenelzine), Marplan (isocarboxazid), and Parnate (tranylcypromine).


Yes

No



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