Submit a case – Bilaxten Contest

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Evaluator Category *

Country Evaluator *

Evaluator First Name *

Evaluator Last Name *

Evaluator Sex *

Email *

Is there a co-author? *

If yes – Co-author Last name & first name *

If yes – Co-author Email *

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Patient Data / Case

Patient Sex *

Is she pregnant? *

Patient's Age *

Relevant medical history *

None
Asthma
Atopic dermatitis
Food allergies
Drug allergy
Hay fever (pollinosis)
Chronic sinusitis
History of chronic hives
Immunodeficiency
Autoimmune disease
Other (Please specify)

If “Other,” please specify *

Location of the pathology *

Pathology duration *

Impact on quality of life

Impact on: Daily activities *

Explanation *

Impact on: Professional life *

Explanation *

Impact on: Personal life *

Explanation *

Impact on: Social life *

Explanation *

Impact on: Self-image *

Explanation *

Impact on: Sleep disturbance *

Explanation *

Other (Please specify)

Previous treatment

For each treatment, please click on the “Add” button and fill in the corresponding information.

Active Ingredient (INN) *

Brand *

Frequency of intake: *

1 times a day
2 times a day
3 times a day
As needed
Other (please specify)

Treatment duration: *

1 day
3 days
7 days
14 days
1 Month
Continuous treatment
Other (please specify)

If “Other” in “Frequency,” please specify *

If “Other” in “Duration,” please specify *

Add another treatment?

Yes
Remove

Active Ingredient (INN) *

Brand *

Frequency of intake: *

1 times a day
2 times a day
3 times a day
As needed
Other (please specify)

Treatment duration: *

1 day
3 days
7 days
14 days
1 Month
Continuous treatment
Other (please specify)

If “Other” in “Frequency,” please specify

If “Other” in “Duration,” please specify

Add another treatment?

Yes
Remove

Active Ingredient (INN) *

Brand *

Frequency of intake: *

1 times a day
2 times a day
3 times a day
As needed
Other (please specify)

Treatment duration: *

1 day
3 days
7 days
14 days
1 Month
Continuous treatment
Other (please specify)

If “Other” in “Frequency,” please specify *

If “Other” in “Duration,” please specify *

Add another treatment?

Yes
Remove

Active Ingredient (INN) *

Brand *

Frequency of intake: *

1 times a day
2 times a day
3 times a day
As needed
Other (please specify)

Treatment duration: *

1 day
3 days
7 days
14 days
1 Month
Continuous treatment
Other (please specify)

If “Other” in “Frequency,” please specify *

If “Other” in “Duration,” please specify *

Add another treatment?

Yes
Remove

Active Ingredient (INN) *

Brand *

Frequency of intake: *

1 times a day
2 times a day
3 times a day
As needed
Other (please specify)

Treatment duration: *

1 day
3 days
7 days
14 days
1 Month
Continuous treatment
Other (please specify)

If “Other” in “Frequency,” please specify *

If “Other” in “Duration,” please specify *

Current treatment

For each treatment, please click on the “Add” button and fill in the corresponding information.

Active Ingredient (INN) *

Brand *

Frequency of intake: *

1 times a day
2 times a day
3 times a day
As needed
Other (please specify)

Treatment duration: *

1 day
3 days
7 days
14 days
1 Month
Continuous treatment
Other (please specify)

If “Other” in “Frequency,” please specify *

If “Other” in “Duration,” please specify *

Add another treatment?

Yes
Remove

Active Ingredient (INN) *

Brand *

Frequency of intake: *

1 times a day
2 times a day
3 times a day
As needed
Other (please specify)

Treatment duration: *

1 day
3 days
7 days
14 days
1 Month
Continuous treatment
Other (please specify)

If “Other” in “Frequency,” please specify *

If “Other” in “Duration,” please specify *

Add another treatment

Yes
Remove

Active Ingredient (INN) *

Brand *

Frequency of intake: *

1 times a day
2 times a day
3 times a day
As needed
Other (please specify)

Treatment duration: *

1 day
3 days
7 days
14 days
1 Month
Continuous treatment
Other (please specify)

If “Other” in “Frequency,” please specify *

If “Other” in “Duration,” please specify *

Add another treatment?

Yes
Remove

Active Ingredient (INN) *

Brand *

Frequency of intake: *

1 times a day
2 times a day
3 times a day
As needed
Other (please specify)

Treatment duration: *

1 day
3 days
7 days
14 days
1 Month
Continuous treatment
Other (please specify)

If “Other” in “Frequency,” please specify *

If “Other” in “Duration,” please specify *

Add another treatment?

Yes
Remove

Active Ingredient (INN) *

Brand *

Frequency of intake: *

1 times a day
2 times a day
3 times a day
As needed
Other (please specify)

Treatment duration: *

1 day
3 days
7 days
14 days
1 Month
Continuous treatment
Other (please specify)

If “Other” in “Frequency,” please specify *

If “Other” in “Duration,” please specify *

Immunotherapy treatment? *

Period of use: *

Reason for choosing this antihistamine *

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Proposed Treatment

Case description *

Drug *

Treatment duration (in days) *

Dosage *

Frequency of intake *

1 times a day
2 times a day
3 times a day
As needed
Other (please specify)

Start date *

End date *

If “Other” in “Frequency of intake,” please specify *

Add another treatment?

Yes
Remove

Drug *

Treatment duration (in days) *

Dosage *

Frequency of intake *

1 times a day
2 times a day
3 times a day
As needed
Other (please specify)

Start date *

End date *

If “Other” in “Frequency of intake,” please specify *

Add another treatment?

Yes
Remove

Drug *

Treatment duration (in days) *

Dosage *

Frequency of intake *

1 times a day
2 times a day
3 times a day
As needed
Other (please specify)

Start date *

End date *

If “Other” in “Frequency of intake,” please specify *

Add another treatment ?

Yes
Remove

Drug *

Treatment duration (in days) *

Dosage *

Frequency of intake *

1 times a day
2 times a day
3 times a day
As needed
Other (please specify)

Start date *

End date *

If “Other” in “Frequency of intake,” please specify *

Add another treatment?

Yes
Remove

Drug *

Treatment duration (in days) *

Dosage *

Frequency of intake *

1 times a day
2 times a day
3 times a day
As needed
Other (please specify)

Start date *

End date *

If “Other” in “Frequency of intake,” please specify *

Results *

Impact level

Daily activity *

Explanation *

Professional life *

Case Current –

Explanation *

Social life *

Explanation *

Self-image *

Explanation *

Disturbed sleep *

Explanation *

Professional/academic performance *

Explanation *

Daily Personal/Social Activity *

Explanation *

Sleep disorders *

Explanation *

VAS (Visual Analog Scale)

Assessment of symptom intensity: 0 = No symptoms; 10 = Very bothersome symptoms

Nasal itching *

Nasal congestion *

Sneezing *

Rhinorrhea *

UAS – Urticaria Activity Score

No. of wheals (0-3)	0 = none	Pruritus (0-3)	0 = none
	1 = <10 wheals		1 = mild
	2 = 10–50 wheals		2 = moderate
	3 = >50 wheals or extensive plaques		3 = severe

Monday – Wheals (0–3)

Selected Value: 1

Monday – Pruritus (0–3)

Selected Value: 1

Tuesday – Wheals (0–3)

Selected Value: 1

Tuesday – Pruritus (0–3)

Selected Value: 1

Wednesday – Wheals (0–3)

Selected Value: 1

Wednesday – Pruritus (0–3)

Selected Value: 1

Thursday – Wheals (0–3)

Selected Value: 1

Thursday – Pruritus (0–3)

Selected Value: 3

Friday – Wheals (0–3)

Selected Value: 1

Friday – Pruritus (0–3)

Selected Value: 1

Saturday – Wheals (0–3)

Selected Value: 1

Saturday – Pruritus (0–3)

Selected Value: 1

Sunday – Wheals (0–3)

Selected Value: 1

Sunday – Pruritus (0–3)

Selected Value: 1

Total UAS7: 0

Adverse events during the observation period? *

Describe them *

Upload a photo (Strongly recommended)

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⚠️ Important: Please ensure that uploaded images do not contain any personally identifiable information (PII) such as the patient’s name, date of birth, medical record number, or any other element allowing direct or indirect identification.

Images must be anonymized before submission. • The use of photographic documentation requires the patient’s authorization to use these photographs in the report/publication. The authorization should not be included but must be available if required.

Add another photo?

Yes
Remove

Upload a photo (Strongly recommended)

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Add another photo?

Yes
Remove

Upload a photo (Strongly recommended)

Drag & Drop Files, Choose Files to Upload

Add another photo?

Yes
Remove

Upload a photo (Strongly recommended)

Drag & Drop Files, Choose Files to Upload

Add another photo?

Yes
Remove

Upload a photo (Strongly recommended)

Drag & Drop Files, Choose Files to Upload

Brief summary explaining why the case is relevant (include up to 5 references) *

(1,000 words maximum)

Consent - Ethics *

I confirm that this file complies with ethical standards.

Basic Data Protection Information (GDPR)

Controller: FAES FARMA, S.A. +info
Purpose: To award the contest prize to the participant.
Legal basis: Consent given at registration and by accepting the privacy policy.
Recipients: FAES FARMA, S.A may share your data with travel service providers and EAACI, in accordance with the contest regulations.
Rights: You have the right to access, correct, or delete your data, as well as other rights described in the additional information. +info
Source: Data provided directly by the data subject. +info
Additional information: Consult all details in our Privacy Policy.

I have read and agree to the above privacy policy. *

Yes, I confirm.

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Email *

Patient Data / Case

Impact on quality of life

Previous treatment

Current treatment

Proposed Treatment

Impact level

VAS (Visual Analog Scale)

UAS – Urticaria Activity Score

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