Eczema Assessment | Pharma Aesthetics

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Eczema Treatment Medical Questionnaire

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Medical Questionnaire

Patient Notice: This Questionnaire forms the basis of your Eczema 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

Do you currently have areas of itchy, red, or inflamed skin that may also be blistered or cracked?*

Yes

No

Please provide more information below.*

Have you noticed your skin becoming excessively dry, sensitive, or prone to bleeding when scratched?*

Yes

No

Please provide more information below.*

Are the affected areas of your skin located in the folds of your arms, behind your knees, on your face, or around your neck?*

Yes

No

Please provide more information below.*

Do your symptoms worsen with exposure to certain triggers, such as soaps, detergents, or changes in weather?*

Yes

No

Please provide more information below.*

Have you experienced a noticeable thickening of the skin or changes in skin colour in the affected areas?*

Yes

No

Please provide more information below.*

Health

Are you currently using any skin products or medications for your eczema?*

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 a personal or family history of eczema, asthma, or allergic conditions?*

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 allergic to any ingredients commonly found in skin care products or medications?*

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 previously been treated for infections in the affected skin areas?*

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, planning to become pregnant, or breastfeeding, as this may influence the choice of eczema 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):*

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 provide a comprehensive understanding of the patient's condition and any factors that may influence the selection and efficacy of eczema treatments offered.

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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