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	Fields marked with a * must be filled in Title: Mr Mrs Ms Miss Dr * Please choose a title Please choose title First name: * Please enter Your Name Surname: * Please enter Your Surname Address line 1: * Please enter Your Address Line 1 Address line 2: Address line 3: Town: * Please enter valid Town name Please enter valid Town name County: Postcode: * Please enter valid Postcode Please enter valid Postcode Telephone number: Mobile telephone number: Email address: * Please enter your email Please enter your email Please enter a valid email Please enter a valid email Gender: Male Female * Month and year of birth: Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Please choose a month Please choose a month 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 * Please choose a year Please choose a year We would like to understand whether you suffer from uncomfortable bowel movements and how this condition affects you. Please take a minute to complete the information below. Who do you ask for health advice? Doctor Pharmacist Other healthcare professional Internet Medical dictionary Family and friends Do not seek advice     Do you dread going to the loo? Yes No Sometimes How often do you suffer? Very often Often Rarely Never How do you treat it? Medicine Alternative remedies No treatment Dietary changes How long have you been treating? Only in the last year 1 - 2 years 3 - 5 years 6 - 10 years 11 - 20 years 20 + years How bothersome do you find the symptoms? Very bothersome Bothersome Not bothersome     How embarrassing do you find the condition? Very embarrassing Embarrassing Occasionally embarrassing Not embarrassing If embarrassing, who, if anyone, have you spoken to? Friend GP Healthcare professional Family Data Protection We may use the information you have provided to update you on, or to seek your opinion on, our products from time to time. This information will not be passed to any third party. If you would prefer us not to contact you for these purposes please untick the box. I would like to receive information and offers from Boehringer Ingelheim Limited by email

DulcoEase. To soften hard, dry stools for a more comfortable way to go to the loo. Contains docusate sodium. Always read the label.