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    Condition Questions

    Have you had this problem diagnosed by a healthcare professional before?

    YesNoOther

    Why do you need treatment today?

    I’ve had this problem before and need a REPEAT prescriptionI’ve had this problem before but want to try a NEW medicationI’ve NOT had this problem before and want to try a medication to helpOther

    Do you have any of the following symptoms? Please select all that apply

    No symptoms right now, but I get recurring cold sores

    Blisters on or around the lips

    Tingling or itching on or around the lips

    Burning or stinging sensation on or around the lips

    Crusting or scabbing on or around the lips

    Redness on or around the lips

    Swelling on or around the lips

    Pain or tenderness on or around the lips

    Bleeding on or around the lips

    Regular infections on or around the lips

    Please tell us more e.g. Where do you get the infection exactly? How many infections have you had in the last year? Have you seen a doctor about this- what did they say?

    Mouth Ulcers or lumps in or around the mouth lasting more than 3 weeks

    Unfortunately we will be unable to treat you due to safety reasons. Please see your GP for further advice.

    Painful white or red patches on the inside surface of the mouth

    Unfortunately we will be unable to treat you due to safety reasons. Please see your GP for further advice.

    Swollen or painful gums

    Unfortunately we will be unable to treat you due to safety reasons. Please see your GP for further advice.

    Difficulty swallowing

    Unfortunately we will be unable to treat you due to safety reasons. Please see your GP for further advice.

    Lesions around your eye

    Unfortunately we will be unable to treat you due to safety reasons. Please see your GP for further advice.

    Other

    I don’t know

    Which areas are affected? Please select all that apply

    Around the mouth
    (near the edges of the lips or surrounding skin)
    On the lips
    (on the upper or lower lips)
    On the gums
    (inside the mouth, on the gum line)
    Inside the cheeksOn the tongueOn or around the noseChin or jawlineGenitalsFingersButtocksThighsNeckShouldersEyesOtherI don’t know

    Unfortunately we do not treat this area due to safety reasons. Please see your GP.

    Unfortunately we do not treat this area due to safety reasons. Please see your GP.

    Unfortunately we do not treat this area due to safety reasons. Please see your GP.

    Unfortunately we do not treat this area due to safety reasons. Please see your GP.

    Unfortunately we do not treat this area due to safety reasons. Please see your GP.

    Unfortunately we do not treat this area due to safety reasons. Please see your GP.

    Unfortunately we do not treat this area due to safety reasons. Please see your GP.

    Have you been diagnosed as having a weakened immune system or HIV? A weakened immune system can be caused by conditions such as HIV, diabetes, autoimmune diseases, or treatments like cancer therapy, steroids, or other immune-suppressing medications

    NoYesI don’t know

    Unfortunately we do not treat this area due to safety reasons. Please see your GP.

    When did the problems start?

    How quickly did the problem start?

    Suddenly (minutes)Quickly (hours)Gradually (days)Slowly (weeks)Very slowly (months)Over several yearsOtherI don't know

    Is it getting worse?

    NoYesOtherI don’t know

    How does the problem behave?

    It's always thereIt comes and goesOtherI don’t know

    How long does it last?

    MinutesHoursDaysWeeksMonthsYears

    Please explain:

    Have you been unwell in any other way recently or experienced any of the following symptoms?

    No- I have been wellI have been unwell recently due to another condition, illness or circumstanceTemperatureFeverNauseaVomitingNight sweatsWeight lossExcessive tirednessJoint pain/ swellingOther concerning symptomsI don’t know

    Please tell us more about how you've been unwell recently

    Please tell us more about your temperature

    Please tell us more about your fever

    Please tell us more about your nausea

    Please tell us more about your vomiting

    Please tell us more about your night sweats

    Please tell us more about your weight loss

    Please tell us more about your tiredness

    Please tell us more about your joint pain/swelling

    Please tell us more about your other concerning symptoms

    Does anything make it WORSE? Please select all that apply

    Stress or anxiety
    (emotional stress or high-pressure situations)

    Sunlight or UV exposure
    (being out in the sun without protection)

    Illness or weakened immune system
    (e.g., colds, flu, or fatigue)

    Hormonal changes
    (e.g., menstrual periods or hormonal fluctuations)

    Physical trauma to the area
    (e.g., cuts, scrapes, or irritation from shaving)


    Dehydration or dry skin/lips
    (dry weather or lack of hydration)

    Extreme temperatures
    (either cold weather or heat)

    Friction or rubbing
    (from clothing, face masks, or frequent touching)


    Medications

    Other

    None of the above

    I don’t know

    Does anything make it BETTER? Please select all that apply

    Applying cold compresses
    (to reduce swelling and pain)

    Avoiding stress
    (using relaxation techniques to lower stress levels)

    Moisturising the lips/skin
    (with lip balms or skin creams)

    Staying hydrated
    (drinking plenty of water to keep the skin and lips moist)

    Avoiding sun exposure
    (using sunscreen or lip balm with SPF)

    Eating a healthy, balanced diet
    (to support the immune system)

    Getting plenty of rest
    (adequate sleep to support the immune system)

    Avoiding acidic or spicy foods
    (to prevent irritation of the affected area)



    Other

    None of the above

    I don’t know

    Have you already tried any of the following treatments?

    Cold Sore Creams/ Ointments
    e.g. Zovirax (Aciclovir), Blistex, Cymex, Abreva (Docosanol)

    Cold Sore Patches
    e.g. Compeed

    Antiviral Tablets/ Capsules
    e.g. Aciclovir, Valciclovir, Famciclovir

    Over-the-counter pain relief
    e.g. Paracetamol, Ibuprofen, Anbesol

    Lip Balms
    e.g. Low-level laser / light therapy for cold sores

    Herbal/ Supplements/ Alternative treatments
    e.g zinc, echinacea, vitamin C

    Other

    None - I haven't tried any treatments.

    What is your biological sex?

    FemaleMaleOther

    Trans Female (Male at birth)Trans Male (Female at birth)

    Are you pregnant, breastfeeding or trying for a baby?

    Yes

    No

    Unfortunately, due to safety reasons we would be unable to prescribe any weight loss treatments for you. Please contact your GP for further help.

    Have you ever been diagnosed with any medical conditions?

    AneamiaAnxiety DisorderAsthmaAtrial Fibrillation (AF)Bipolar DisorderCancer (Past or Present)CholecystitisCOPDCrohnsDepressionEczemaEpilepsyFolic acid deficiencyMigraineMyasthenia GravisObsessive-Compulsive DisorderOsteoarthritisOsteoporosisPancreatitisPeripheral Vascular DiseasePsoriasisRaynaud’sRheumatoid Arthritis

    Gastric Reflux DiseaseGastric SleeveHay FeverHeart ArrhythmiaHeart Disease/ Heart AttackHeart FailureHigh Blood PressureHigh CholesterolInflammatory Bowel DiseaseIron deficiencyIrritable Bowel Syndrome (IBS)Kidney DiseaseLiver DiseaseStroke/ TIASurgeryThyroid DisordersType 1 DiabetesType 2 DiabetesUlcerative ColitisVitamin D deficiencySchizophreniaSjorgen’s syndrome

    None of the above

    Other

    Please provide details about your cancer diagnosis:

    Please provide details about any previous or upcoming surgeries:

    Please explain other medical conditions:

    Do you currently take any medications, vaccines, supplements, or recreational drugs?

    NoMedicationsOver the counter medications/ herbal medicationsSupplements

    Recreational drugsVaccinesOther

    Please tell us which medications you are currently taking:

    Please tell us what over-the-counter or herbal medications you are currently taking:

    Please tell us what supplements you are currently taking:

    Please tell us what recreational drugs you are currently using:

    Please tell us if you will be having any vaccines at the same time as using this medication:

    Please tell us what else you take:

    Do you have any allergies to any medications, supplements, herbs, chemicals, peanuts, soya or anything else we should be aware of?

    Yes

    No

    Please tell us more:

    Is there anything else you feel is important for us to know that would prevent us from safely prescribing for you?

    Yes

    No

    Photo Upload

    • If this is a new problem then we require at least one photo of it (max 6 photos) using your phone or digital camera.

    • Take a "far away photo" (from 1 meter away) to show the location and size of the problem.

    • Take a close-up photo (10-12 cm away) to show the details.

    • If appropriate please include a size reference (e.g. a coin or ruler) in your photo for scale.

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    GP Details

    By providing these details, you consent to us sharing relevant information with your GP if necessary for safety purposes, accessing your NHS Summary Care Record, or obtaining further details about your medical history.

    Do you understand and agree with the following?

    You should seek medical advice if cold sores are getting worse or not healing after 10 days.

    You understand the difference between the two doses of Aciclovir for cold sores:

    • Treatment dose: 400mg three times a day for 5 days to treat a single outbreak.

    • Suppressive dose: 400mg twice a day to prevent future outbreaks.

    If you are on suppressive treatment (Aciclovir 400mg twice daily) and have had a cold sore outbreak, you should consult your GP for advice. You should consider stopping suppressive treatment if you have had no outbreaks after 6 months and consult your GP if you wish to continue up to 12 months. A break in treatment is recommended after 12 months.

    You are aware you should not use Aciclovir tablets and should consult your GP if you are having cold sores and have been diagnosed with any of the following:

    • Reduced immunity (e.g., after a bone marrow transplant, low white blood cell count, or HIV, after taking immunosuppressive medications)

    • Neurological illness

    • Long-standing low oxygen levels

    • Abnormal liver blood test results

    • Blood chemistry abnormalities

    • Severe kidney disease

    • If you are taking any of the following interacting medications: Mycophenolate, Theophylline/Aminophylline, or any medication that may impair your kidneys

    Aciclovir cream is not for internal use or for use in or around the eye. It should not be used in the vagina, anus, or inside the mouth.

    You are aware that if you have or develop severe symptoms, new or worsening symptoms or concerns, or psychological distress, or your condition is not responding to treatment, then you should see your GP as soon as possible.

    You will read the patient information leaflet supplied with any medication we send you, and if you have any allergies to any of the ingredients or any contraindications, you will not take the medication and contact a DigiDerm clinician for further advice. You have informed us of any allergies you have by completing the general health questions.

    You have informed us of any current or previous medical conditions you have by completing the general health questions.

    You are not pregnant.

    You agree that if needed, a DigiDerm clinician may contact you via email or telephone in response to this consultation form to offer advice and suggest treatments where necessary, or if they feel they need more information to make an accurate diagnosis or assessment of your condition.

    You agree that if, after reviewing your consultation, your skin problem is something we cannot treat or is not suitable for our service, then we will give you a full refund and suggest you visit your registered NHS GP for further advice.

    You are at least 16 years old and currently resident in the UK at the time of this consultation. This treatment is to be used only by you.

    You take responsibility to inform your own regular doctor/NHS GP of this online consultation and any treatments supplied, or any changes in your circumstances.

    The answers provided to the above questions are true and accurate to the best of your knowledge.


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