Eczema consultation

Eczema-Consulation

Patient details

Please complete the consultation as accurately as possible.

Are you completing the consultation for yourself?

Skin condition

Please complete the consultation as accurately as possible.

Just like a traditional consultation we're going to ask you about your medical history and symptoms. Your answers will help us assess your suitability for treatment. Please answer all questions to the best of your knowledge and in full. If you have any problems understanding or answering a question please call on 01493600610.
Have you been diagnosed with eczema by a GP or dermatologist?
Which of the following symptoms are you currently experiencing?
Which parts of your body are affected by eczema?
Do you suffer from asthma or hay fever?
Is there any family history of Eczema/Asthma/Hay fever?
Is your eczema worsened by any of these?
Other than your skin condition are you experiencing any of the following?
What treatments are you currently using for eczema? (Tick all that apply)
Other than those already mentioned, do you have any other significant medical conditions, illnesses, hospital stays or past surgical procedures?
Are you taking any other prescription-only medicines, over-the-counter medicines, alternative medicines or recreational drugs?
Do you have any known allergies?
Are you currently pregnant or breastfeeding?
Consent

Photo upload

Please upload at least 2 photos of affected areas - one close-up and the other from distance.

Caution:
Please do not upload photos of private parts.