Acne Assessment | Pharma Aesthetics

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Acne Treatment Medical Questionnaire

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Medical Questionnaire

Patient Notice: This Questionnaire forms the basis of your Acne Treatment consultation today. We need you to be honest with your answers including any current medications you are on. This allows our doctors to prescribe medication that helps you and offer accurate advice. We expect you to read the medical information before selecting your treatment.

Your Symptoms

Have you seen a doctor face to face and been diagnosed with acne?*

Yes

No

Please provide more information below.*

How would you describe the spots that appear on your skin? Please select an option:*

Whiteheads / Blackheads

Inflammation on the skin surface

Pustules on skin

Are you aware oral Lymecycline antibiotics should not be taken whilst using Zineryt Solution or Duac Gel?*

Yes

No

Please Confirm

I understand and confirm that oral Lymecycline antibiotics should not be taken whilst using Zineryt Solution or Duac Gel.

Are you aware Lymecycline antibiotics are best used with topical Differin, Epiduo or Benzoyl Peroxide Gels? This reduces the chance of the bacteria developing antibiotic resistance.*

Yes

No

Please Confirm

I understand and confirm that Lymecycline antibiotics are best used with topical Differin, Epiduo or Benzoyl Peroxide Gels, reducing the chance of the bacteria developing antibiotic resistance.

Health

Do you suffer any problems with your kidneys or other organs like liver, urinary or digestive systems?*

Yes

No

Please provide more information (we ask this question so our doctors can make sure any treatment they prescribe is safe for you):*

Have you ever had an allergic reaction to antimalarial medication or do you have any known drug allergies?*

Yes

No

Please provide more information (we ask this question so our doctors can make sure any treatment they prescribe is safe for you):*

Are you currently taking any prescription-only medicines, alternative medicines or recreational drugs?*

Yes

No

Please provide more information (we ask this question so our doctors can make sure any treatment they prescribe is safe for you):*

Do you have any known allergies to any medicine or substances?*

Yes

No

Please provide more information (we ask this question so our doctors can make sure any treatment they prescribe is safe for you):*

Are you pregnant or planning to become pregnant or breastfeeding?*

Yes

No

Please provide more information (we ask this question so our doctors can make sure any treatment they prescribe is safe for you):*

Differin, Epiduo and Lymecycline should not be used if pregnant or planning to become pregnant.

Acknowledgements

Please Confirm

I understand if I start to experience any symptoms that seem out of the ordinary, I must see a GP.

These questions aim to ensure that any prescribed Acne Treatments are both effective and safe for the patient, considering their current health status.

Consent

We strongly advise that you inform your GP of any treatment you receive, Would you like us to inform them on your behalf?*

Yes

No

Your GP Address Details

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Your Details

Name*

First Last

Phone*

Date of Birth*

Day

Month

Year

Your Home Address*

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Please Confirm

Confirmation*

I Confirm

• I confirm I am over 18 years old
• The medicine is ordered for myself
• I will read the patient information leaflet supplied with the medicine and specifically the side effects and dosages
• I take responsibility to inform my own regular doctor of this online consultation or any changes in my circumstances.
• I agree to the Pharma Aesthetics Terms and Conditions.

If treatment is not suitable, you will be refunded and signposted to another point of care. The decision about treatment is for both the patient and the prescriber to consider, however, the final decision will always lie with the prescriber.

Name

This field is for validation purposes and should be left unchanged.

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16 Broadway, Rainham, Essex, RM13 9YW
01708 608860
info@pharma-aesthetics.co.uk

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