Personal Care Products
Are there any personal care products containing fragrances or scents that cause you to have adverse health reactions?
(check all that apply) |
1. Perfumes/Colognes:
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| Yes |
| No |
| If yes, please check all applicable symptoms: |
| Headaches Burning/itching eyes Breathing Difficulty Skin Rash Nausea Asthma Attack Coughing Sinus, Nose, Throat, Mouth, Lung Irritation Other
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| Of the products that bother you, please list the top three brands; form of delivery; and amount used: |
| Brand 1. |
| Form of Delivery: Aerosol/Pump Spray Splash/Lotion
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| Amount Used: Pulse Points All Over
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Brand 2. |
| Form of Delivery: Aerosol/Pump Spray Splash/Lotion
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| Amount Used: Pulse Points All Over
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Brand 3. |
| Form of Delivery: Aerosol/Pump Spray Splash/Lotion
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| Amount Used: Pulse Points All Over
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