General Information

Information Concerning Zicam Use

Was Zicam suggested by your physician? Yes No

Reason for its use ?

Date of first use?

Date stopped?

Identify the type of product(s) used and when:

Zicam Cold Remedy Nasal Gel
Zicam Cold Remedy Nasal Swabs
Zicam Cole Remedy Swabs, Kids Size

Be sure to keep all receipts, containers, packaging
or any remaining product in a safe place.

Have you received a recall letter from your physician or pharmacist? Yes No

Have you used other brands of nasal cold remedy or allergy products in the past?
Yes No

Have you been diagnosed with a loss of the sense of smell? Yes No

If Yes, when were you diagnosed?

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