a. Pain relievers such as aspirin (or Tylenol and the like)?

[] Y
[] N

b. Cough medicines (such as Vicks, Robitussin, or Phenergan Expectorant and the like)?

[] Y
[] N

c. Any other medicines or remedies for colds?

[] Y
[] N

d. Asthma or allergy pills or medicines (such as Benadryl, Dimetapp, or Sudafed and the like)?

[] Y
[] N

e. Topical steroids (such as hydrocortisone cream or valisone and the like)?

[] Y
[] N

f. Other skin ointments or salves (such as Desitin, Calomine Lotion, Vaseline, Clearasil and the like)?

[] Y
[] N

g. Laxatives or any other medicines or remedies for the stomach (such as Ex-Lax, Rolaids, Colace, or Donnatal and the like)?

[] Y
[] N

h. Vitamins or minerals?

[] Y
[] N

i. Tranquilizers or sedatives (such as Valium, Chloral Hydrate, or Secanol and the like)?

[] Y
[] N

j. Antibiotics (such as Penicillin, Tetracycline, Ampicillin and the like)?

[]Y
[] N

k. Are there any other pills, ointments, or other types of medicines that -- has taken or used during that 2 week period? - Specific

[] Y
[] N

Any others?

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K2 ____
K3 ____