Search
Rhinocort Aqua (budesonide) Nasal Spray

Allergy Assessment Form

Not sure if you have nasal allergies? Take this simple assessment to create your personal Nasal Allergy Profile that you can print and share with your doctor. You can also use the Self-Assessment Checklist for your child, to help his or her doctor understand his or her symptoms.

AstraZeneca respects your personal health information. The information you provide may be used to send you health-related materials and to develop products, services, and programs. AstraZeneca, or third parties working on our behalf, will not sell or rent personal health information. Please visit www.azprivacystatement.com to review our Privacy Statement.

DIRECTIONS:

Answer the following questions. When you are finished, click "Create My Nasal Allergy Profile." You will then receive a checklist that is customized especially for you!

First Name:
Last Name:

    1. What nasal allergy symptom(s) have you had? (Check all that apply.)
        Nasal congestion     Sneezing     Runny nose
        Other

    2. How severe are your nasal allergy symptoms, on average?
        Severe
        Moderate
        Mild
        Occasional
        My nasal allergy symptoms really don't bother me

    3. Do your nasal allergy symptoms appear or get worse after dusting or doing      other household chores?
        Yes
        No

    4. Do your nasal allergy symptoms appear or get worse when you are around furry or feathered animals?
        Yes
        No

    5. Do your nasal allergy symptoms appear or get worse when you are outside?
        Yes
        No

    6. Do your nasal allergy symptoms appear or get worse when you rake leaves      or go down in the basement?
        Yes
        No

    7. Do your nasal allergy symptoms appear or get worse in your workplace?
        Yes
        No

    8. When do you have nasal allergy symptoms? (Check all that apply.)

     All year
     January  February  March  April
     May  June  July  August
     September  October  November  December

    9. The following list contains risk factors for developing nasal allergies. (Check      all that apply.)
        I have at least 1 parent with nasal allergies.
        I weighed less than 5 ½ pounds at birth.
        I was bottle-fed as an infant.
        Growing up, I was exposed to cigarette smoke at home.
        We have furry/feathered pets at home.
        I was born during a peak pollen or mold season (spring, summer, early            fall).

    10. Who treats your nasal allergies?
        Family doctor or primary care physician
        Pediatrician
        Allergist
        Ear, nose, throat specialist (ENT)
        Herbalist or naturopath (alternative medicine practitioner)
        Other
        No one yet; I'm still seeking treatment
        I treat myself

    11. Have you had any diagnostic tests (such as skin-scratch tests) for your       nasal allergies?
        Yes
        No, but I'm interested
        No, my nasal allergies aren't that bad

    12. Have you ever had allergy shots?
        Yes
        No, but I'm interested
        No, my nasal allergies aren't that bad

    13. Are you currently using any prescription nasal allergy medications? (Check       all that apply.)
        Allegra® (fexofenadine HCl)
        Clarinex® (desloratadine)
        Generic - fluticasone propionate
        Nasacort® AQ (triamcinolone acetonide)
        Nasonex® (mometasone furoate monohydrate)
        RHINOCORT AQUA® (budesonide) Nasal Spray
        Vancenase AQ 84® (beclomethasone dipropionate)
        Zyrtec® (cetirizine HCl)
        Other
        None

    14. Are you currently using any over-the-counter allergy medications? (Check       all that apply.)
        Antihistamines (eg, Contac®, Claritin®, Alavert™, Benadryl®,              Chlor-Trimeton®)
        Nasal decongestants (eg, Afrin®, Neo-Synephrine®, Dristan® Nasal)
        Oral decongestants (eg, Sudafed®)
        Combination products (eg, Actifed®, Tavist-D®)
        Other
        None

    

Prescription Product Name and Trademark Information

Flonase; Nasonex; Nasacort AQ; Vancenase AQ 84; Allegra; Alavert; Zyrtec; Claritin and Clarinex; Actifed, Benadryl and Sudafed; Contac; Tavist-D; Neo-Synephrine; Afrin and Chlor-Trimeton are trademarks of their respective owners and are not trademarks of the AstraZeneca group of companies. The makers of these brands are not affiliated with and do not endorse AstraZeneca or its products.

RHINOCORT AQUA is a trademark of the AstraZeneca group of companies.

Indication and Important Safety Information

RHINOCORT AQUA (budesonide) is for the management of seasonal and year-round nasal allergy symptoms in adults and children 6 years of age and older.

The most commonly observed side effects associated with the use of RHINOCORT AQUA in clinical studies were nosebleed, sore throat, nasal irritation, cough and breathing difficulties such as wheezing, chest tightening or coughing due to airway constriction.

Your doctor may prescribe RHINOCORT AQUA at a dose of 1 to 4 sprays per nostril once daily. Take RHINOCORT AQUA exactly as directed.

Your nasal allergy symptoms may begin to improve within 10 hours after first using RHINOCORT AQUA. In one group of patients that were studied, RHINOCORT AQUA and the nasal spray mometasone furoate (a medication used for comparison in the study) both improved nasal allergy symptoms within 8 hours. However, you must continue to take your medication every day, as directed by your doctor. Your nasal allergy symptoms will continue to improve over the first few days, and maximum relief may take about 2 weeks to achieve.

Please click here for full Prescribing Information

This product information is intended for US consumers only. RHINOCORT AQUA is a registered trademark of the AstraZeneca group of companies.

©2008 AstraZeneca LP. All rights reserved. 257666 2/08

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.

AstraZeneca