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cold sore Assessment

Cold Sore Treatment Medical Questionnaire

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Medical Questionnaire

Patient Notice: This Questionnaire forms the basis of your Cold Sore 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 noticed any small, painful blisters on or around your lips, mouth, or nose area?*

Yes

No

Please provide more information below.*

Are you experiencing tingling, itching, or burning sensations around your lips or mouth before the appearance of blisters?*

Yes

No

Please provide more information below.*

Have the blisters progressed to open sores or ulcers that are oozing fluid before crusting over?*

Yes

No

Please provide more information below.*

Do you have any symptoms of a secondary infection, such as fever, swollen lymph nodes, or a sore throat, accompanying the cold sores?*

Yes

No

Please provide more information below.*

Have you had a previous outbreak of cold sores in the past?*

Yes

No

Please provide more information below.*

Health

Are you currently taking any immunosuppressive medications or do you have a condition that affects your immune system?*

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 antiviral medications or ingredients commonly found in cold sore treatments?*

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 breastfeeding, which might affect the choice of treatment?*

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 been diagnosed with any chronic skin conditions, such as eczema, that could be affected by cold sore outbreaks?*

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 undergoing treatment for any other viral infections?*

Yes

No

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

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 are designed to gather essential information about the patient's cold sore symptoms and their overall health, which is crucial for prescribing an effective and safe treatment plan.

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.

Email

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

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