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* Allergy sufferer's date of birth:  -  01 02 03 04 05 06 07 08 09 10 11 12  /   -  01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31  /  - Select - 1902 1903 1904 1905 1906190719081909191019111912191319141915191619171918191919201921192219231924192519261927192819291930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002

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Now, just answer these 3 simple questions. If the allergy sufferer is a child, please answer the questions on your child's behalf.

1. Which of the following medications do you take to treat the symptoms associated with your nasal allergies? (Select all that apply.)

Allegra®/Allegra-D®*  FLONASE®  Zyrtec®/Zyrtec-D®*  Astelin®*  Nasacort®*  Other  Atrovent®*  Nasonex®*  I do not take any prescription medications for my nasal allergies.  Clarinex®*  Rhinocort Aqua®*  Claritin®/Claritin-D®*  Singulair®*

*The brands listed are trademarks of their respective owners and are not trademarks of The GlaxoSmithKline Group of Companies. The makers of these brands are not affiliated with and do not endorse GlaxoSmithKline or its products.

2. Has a doctor or healthcare provider ever told you that you suffer from nasal allergies?  Yes   No 3. Does anyone else in your household suffer from nasal allergies?  A child/children under the age of 4  A child/children between the ages of 4 and 18  Another adult  No one else in my household suffers from nasal allergies

By providing your name, address, e-mail address, and other information, you are giving GlaxoSmithKline (GSK) and companies working with GSK permission to market or advertise to you regarding the medical condition(s) in which you've expressed an interest, as well as other general health related information from GSK. GlaxoSmithKline will not sell or transfer your name, address, or e-mail address to any other party for their own marketing use. For additional information on how GSK handles your information, please read our privacy statement.

Important Information about FLONASE

FLONASE is approved for the treatment of seasonal and year-round nasal allergies, and year-round non-allergy nasal symptoms, in people 4 years of age and older. For best results, use FLONASE daily. Your symptoms may begin to improve in as few as 12 hours. Maximum relief may take several days. Results may vary. If side effects occur, they are generally mild and may include headache, nosebleed, or sore throat. Complete Prescribing Information for FLONASE® (fluticasone propionate) Nasal Spray, 50 mcg.