Rxpress

Skin Condition Consultation Form

To help us direct you to the appropriate clinician, please select the reason for your consultation request:

—Please choose an option—EczemaDermatitisAcneRosaceaPsoriasisImpetigoOther

Date of Birth (DD/MM/YYYY):

Age:

Full Name:

Home Address:

Email:

Telephone:

Name & Address of GP:

Would you like your GP to be informed of this consultation?
YesNo

Skin Condition Assessment

Where is the problem located on your body?

When did the condition first appear?

What does the rash/skin issue look or feel like (e.g. dry, itchy, flaky, red, blistering)?

Has the condition spread to other areas?

Associated symptoms: Are there other symptoms (e.g. fever, pain, swelling, discharge)?

Is the condition constant or does it come and go?

Is anything making it better or worse (e.g. creams, temperature, stress)?

How severe is the condition? (e.g. pain scale 1-10, impact on daily life)

Medical Background

Have you had this skin condition before?
YesNo

Do you have any known allergies?
YesNo

If yes, please provide details:

Are you currently taking any medication (prescription or over-the-counter)?
YesNo

Please list any medications you are currently taking:

Do you have any chronic medical conditions (e.g. eczema, psoriasis, asthma, diabetes)?
YesNo

If yes, please provide details:

Do we have permission to access your medical records?
YesNo