We ask these questions to ensure that any medication prescribed is safe based on your biological sex and pregnancy status.
What was your sex assigned at birth?
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Are you currently pregnant or breastfeeding?
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I understand that the medication prescribed to me by my healthcare provider may not be safe to take during pregnancy. I acknowledge that taking this medication while pregnant could pose risks to my health and the health of a developing fetus.
I agree to take necessary precautions to avoid becoming pregnant while using this medication, including the use of effective contraception methods as discussed with my healthcare provider.
I understand that I should stop taking this medication before attempting to become pregnant. I agree to consult with my healthcare provider prior to discontinuing the medication and before planning a pregnancy to ensure my safety and well-being.
By selecting below, I confirm that I have read and understand the information provided above. I consent to proceed with the treatment under these conditions.
I agree to take necessary precautions to avoid becoming pregnant while using this medication, including the use of effective contraception methods as discussed with my healthcare provider.
I understand that I should stop taking this medication before attempting to become pregnant. I agree to consult with my healthcare provider prior to discontinuing the medication and before planning a pregnancy to ensure my safety and well-being.
By selecting below, I confirm that I have read and understand the information provided above. I consent to proceed with the treatment under these conditions.
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Medical History
Medical History
When were you first diagnosed with allergies?
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Medical History
Medical History
Have you undergone formal allergy testing (such as skin prick testing or specific IgE blood tests)?
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Allergy History
Allergy History
Have you experienced any complications or side effects from previous allergy treatments?
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Allergy History
Allergy History
Do you have any coexisting conditions such as asthma, eczema, or recurrent sinusitis?
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Current Symptoms
Current Symptoms
How would you rate the severity of your current symptoms?
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Current Symptoms
Current Symptoms
How frequently do these symptoms occur?
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Current Symptoms
Current Symptoms
Do your symptoms interfere with your sleep, work, or daily activities?
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Current Symptoms
Current Symptoms
Do you spend a significant amount of time outdoors during peak pollen seasons?
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Current Symptoms
Current Symptoms
Are you exposed to known environmental triggers at home or work (eg, dust, mold, pet dander, pollution)?
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Current Symptoms
Current Symptoms
Have you ever undergone allergy testing for this type of pet?
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Current Symptoms
Current Symptoms
Do you use environmental control measures such as air purifiers, HEPA filters, or dehumidifiers?
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Current Symptoms
Current Symptoms
Are you currently taking any medications for your allergies?
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Current Symptoms
Current Symptoms
Would you like to continue this product?
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Indication for Use:
You are requesting treatment with allergy medications as part of your treatment plan for allergies. Your treatment may include any of the following medication classes:
Second-Generation Oral Antihistamines:
These medications work by targeting different pathways involved in the allergic response—such as blocking histamine receptors, reducing inflammation, or modulating leukotriene activity—to help alleviate symptoms such as sneezing, itching, runny nose, and watery eyes.
Potential Benefits:
While these medications can be beneficial, they may also cause side effects. In rare cases, they can result in severe reactions requiring emergency care. Common and serious side effects include, but are not limited to:
Common Side Effects:
You are requesting treatment with allergy medications as part of your treatment plan for allergies. Your treatment may include any of the following medication classes:
Second-Generation Oral Antihistamines:
- Examples: Zyrtec, Cetirizine, Claritin, Loratadine, Xyzal, Levocetirizine, Clarinex, Desloratadine, Allegra, Fexofenadine
- Examples: Fluticasone, Mometasone, Budesonide
- Examples: Azelastine, Olopatadine
- Example: Azelastine + Fluticasone
- Example: Montelukast
These medications work by targeting different pathways involved in the allergic response—such as blocking histamine receptors, reducing inflammation, or modulating leukotriene activity—to help alleviate symptoms such as sneezing, itching, runny nose, and watery eyes.
Potential Benefits:
- Reduction or resolution of common allergy symptoms (e.g., sneezing, runny nose, itching)
- Improved ability to engage in daily activities with fewer allergy-related disruptions
- Potential improvement in quality of life due to better symptom control
While these medications can be beneficial, they may also cause side effects. In rare cases, they can result in severe reactions requiring emergency care. Common and serious side effects include, but are not limited to:
Common Side Effects:
- Mild drowsiness or sedation (more common with oral antihistamines)
- Dry mouth, nose, or throat
- Headache
- Nausea or upset stomach
- Dizziness
- Local nasal irritation (with intranasal formulations)
- Fast or irregular heartbeat (tachycardia, palpitations), particularly with oral antihistamines
- Significant drowsiness or confusion (especially if combined with other sedating agents or alcohol)
- Severe allergic reactions (rash, itching, swelling, difficulty breathing)
- Worsening of existing medical conditions (e.g., glaucoma, urinary retention, certain heart conditions)
- Cardiovascular Disease/High Blood Pressure: Oral antihistamines have been associated with severe tachycardia and palpitations. Discuss use with your provider if you have heart disease or hypertension.
- Kidney or Liver Problems: Dose adjustments may be necessary if you have impaired kidney or liver function.
- Alcohol Dependence: Combining these medications with alcohol can increase sedation and other effects.
- Fever or Sinusitis: Allergy-like symptoms may be due to an infection; if you have a recent high fever or sinusitis, further evaluation may be needed.
- Respiratory Conditions (Asthma, COPD, Cystic Fibrosis): Some allergy medications may not address all respiratory symptoms; additional evaluation or different therapy may be required.
- Eye Conditions (Glaucoma or Cataracts): Certain medications may worsen these conditions; please discuss with your provider.
- Mental Health Disorders: Some medications may increase sedation or interact with treatments for anxiety or depression.
- Epilepsy: Certain allergy medications can lower the seizure threshold; caution is advised.
- Structural or Autoimmune Conditions: If you have frequent nosebleeds, nasal obstructions, or conditions such as Wegener’s syndrome, sarcoidosis, or autoimmune disorders (e.g., rheumatoid arthritis, Sjögren’s syndrome, lupus), your symptoms may require further investigation or referral.
- Generally, these allergy medications do not require routine laboratory monitoring when used as directed.
- If you have comorbidities (e.g., kidney or liver disease) or are taking other medications, your provider may recommend periodic check-ins to ensure safe use.
- Contact your healthcare provider immediately if you experience unusual or severe side effects, such as significant drowsiness, difficulty breathing, or heart palpitations.
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Please attest to the following confirming that all information you have provided to us is true and complete.
I verify that I am the patient and that I have answered the questions asked in this intake form. I confirm that I have reviewed and understood all the questions asked of me. I attest that the answers and information I have provided in this questionnaire is true and complete to the best of my knowledge. I understand that it is critical to my health to share complete health information with my doctor. I will not hold the doctor or affiliated medical practice responsible for any oversights or omissions, whether intentional or not, in the information that I provided.
I verify that I am the patient and that I have answered the questions asked in this intake form. I confirm that I have reviewed and understood all the questions asked of me. I attest that the answers and information I have provided in this questionnaire is true and complete to the best of my knowledge. I understand that it is critical to my health to share complete health information with my doctor. I will not hold the doctor or affiliated medical practice responsible for any oversights or omissions, whether intentional or not, in the information that I provided.
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Based on the information you provided, this visit type requires in-person medical evaluation for safe and appropriate care.
What you were seeking help for:
• Allergy
Why this happens
Some symptoms, medical history details, or risk factors mean a condition can’t be safely managed through telemedicine. A licensed provider must examine you in person to ensure the right diagnosis and treatment.
Please visit a local urgent care, primary care clinic, or emergency department if your symptoms worsen.
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© 2026 OrderlyCares. All Rights reserved
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