Rosacea Assessment | Pharma Aesthetics

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Rosacea Treatment Medical Questionnaire

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Medical Questionnaire

Patient Notice: This Questionnaire forms the basis of your Rosacea 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 frequently experience flushing or redness on your face, particularly on your cheeks, nose, chin, or forehead?*

Yes

No

Please provide more information below.*

Have you noticed small, red, pus-filled bumps or pimples on your face?*

Yes

No

Please provide more information below.*

Do you experience burning or stinging sensations on your face, especially when applying skincare products or in reaction to certain factors?*

Yes

No

Please provide more information below.*

Are there visible blood vessels (telangiectasia) on your face?*

Yes

No

Please provide more information below.*

Do you have any issues with your eyes, such as dryness, irritation, or swollen, reddened eyelids (known as ocular rosacea)?*

Yes

No

Please provide more information below.*

Health

Are you currently using any topical or oral medications for your skin condition?*

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 previously diagnosed with rosacea by a healthcare professional?*

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 skincare products or medications commonly used to treat rosacea?*

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 type of treatments recommended for you?*

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 other medical conditions or are you taking any medications that could affect your skin or interact with rosacea 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 effectiveness of rosacea treatments.

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

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