RATE YOUR SYMPTOMS

Not sure how to describe your allergies to your healthcare provider? Use this helpful tool to figure out your symptoms, and get a sense of how serious they are. Then, just print out the results and show them to your healthcare provider.

My allergies:

I experience:	Often	Sometimes	Never
Itchy eyes
Eye redness
Swelling of the eyelids
Tearing or watery eyes
Feeling something is in my eye

Severity of my symptoms

What I have been doing for these eye allergy symptoms up to now (check all that apply)

Nothing

Home remedies (like cold, wet compresses)

Using prescription allergy medication (check all that apply)

Pills

ALLEGRA* CLARINEX* ZYRTEC*
Other

Nasal Sprays

FLONASE^® * Other

Eye Drops

PATADAY^™ solution PATANOL^® solution VISINE*
Other

Using nonprescription, over-the-counter medications, such as pills, nasal sprays and/or eye drops (list all that apply)

Are your current remedies/medications helping your eye allergy symptoms?

Yes No

Effectiveness of medications for my eye allergy symptoms:

My satisfaction with how fast these medications work is:

	Not Satisfied	Barely Satisfied	Moderately Satisfied	Very Satisfied

My satisfaction with how long these medications work is:

	Not Satisfied	Barely Satisfied	Moderately Satisfied	Very Satisfied

* Trademarks are the property of their respective owners

You are encouraged to report negative side effects of prescription drugs to the FDA. Visit www.fda.gov/medwatch, or call 1-800-FDA-1088.

IMPORTANT SAFETY INFORMATION: PATADAY^™ solution is indicated for the treatment of ocular itching associated with allergic conjunctivitis. PATADAY^™ solution is contraindicated in patients with a hypersensitivity to any components of this product. Patients who wear soft contact lenses and whose eyes are not red should be instructed to wait at least ten minutes after instilling PATADAY^™ solution before they insert their contact lenses. Safety and effectiveness in pediatric patients below the age of 3 has not been established. The most common adverse reactions to PATADAY^™ solution were cold syndrome and pharyngitis reported at an incidence of approximately 10%. Other adverse events included eye pain, blurred vision, sinusitis and headache occurring in 5% or less of the patients. The recommended dose is one drop in each affected eye once-a-day.
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	N/A	Mild	Moderate	Severe	Very Severe
Itching
Redness
Swelling
Tearing
Feeling something is in my eye

	Not Effective	Barely Effective	Moderately Effective	Very Effective
Itching
Redness
Swelling
Tearing