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

    Where on your body is the problem?

    FaceChestBackShouldersButtocksOther

    Face

    ForeheadBoth CheeksLeft CheekRight CheekNoseJaw lineChinCentre of face (down the middle)

    Chest

    Entire chestLeft sideRight sideIn Between Breasts

    Back

    UpperMiddleLowerAll over

    Shoulders

    LeftRightBoth

    Buttocks

    Butt CheeksBum Fold (skin fold)

    0%

    Do you have any of the following symptoms?

    Whiteheads (small pus-filled pimples)Blackheads (small black pimples)Papules (small hard pimples)Pustules (small pus-filled spots)Cysts (large fluid filled lumps)Greasy/ Oily skinDry skinRednessItchy/ flakey skin affecting the eyebrows, side of the nose or earsYellowish crusting of the skinStinging/ BurningSkin warm to the touchBleedingCrustingScarringSwellingPain/ SensitivityFlushing (sudden reddening of the face)Excessive hair growth on bodyChanges in your menstrual periodWeight gainEye Problems e.g. grittiness, dryness, irritation, sensitivity, bloodshotNone of the aboveOtherI don’t know

    Please rate your pain on a scale of 1-10, 1 being very little and 10 being the worst pain imaginable:

    Please tell us more about your flushing

    Please tell us more about this hair growth on your body

    Please tell us more about the changes in your periods

    Please tell us more about your weight gain

    Please tell us more about your eye problems

    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

    11%

    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 have 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

    22%

    Does anything make it WORSE?

    StressSpicy foodsMedicationsAlcoholCaffeineHeatColdExerciseSunlightOtherNone of the aboveI don’t know

    Please explain

    Does anything make it BETTER?

    HeatColdExerciseSunlightSea WaterCertain products e.g. cosmetics, aloe vera, tea tree oil, green teaCertain supplements e.g. vitamins, zinc, probioticsDietOtherNone of the aboveI don’t know

    33%

    Have you already tried any of the following treatments?

    Cleansers/ Exfoliators
    e.g. Cetaphil, CeraVe, Purifide, La Roche Posay Effaclar, Neutrogena

    Moisturisers
    e.g. CeraVe Aveeno, Aloe vera, La Roche Posay Effaclar, Neutrogena

    Benzoyl Peroxide gels/ creams//washes
    e.g. Clearasil, Acnecide gel, PanOxyl, Clean and Clear

    Retinoid creams/ gels
    e.g. Differin, Epiduo, Isotrex, Treclin, Aklief

    Azelaic acid creams/gels
    e.g. Skinoren, Finacea

    Combination creams/gels
    e.g. Duac, Epiduo, Treclin

    Antibiotic creams/ gels/ lotions
    e.g. Duac, Zineryt, Dalacin-T, Rozex, Metrogel

    Antibiotic tablets/capsules
    e.g. Lymecycline, Doxycycline, Clarithromycin, Erythromycin, Trimethoprim

    Specialist Acne treatments
    e.g. Spironolactone, Isotretinoin, Dianette contraceptive pill

    Immune Suppressing tablets/injections
    e.g. Methotrexate, Azathioprine, Hydroxychloroquine, Mycophenolate, Ciclosporin

    Biologics
    e.g Humira injection, Remicade injection

    Cosmetic procedures
    e.g. Chemical peels, Micro-needling, Dermal fillers, Botox

    Laser/ Light/UV therapy

    Herbal/ Supplements/ Alternative treatments
    e.g tea tree oil, zinc, vitamins

    Surgical Procedures

    Other

    None - I haven't tried any treatments.

    44%

    What is your current Weight and Height?

    Weight:

    KgStones & Pounds


    Height:

    CmFeet & Inches


    Your BMI is: --

    Are you currently up to date with your smear tests (cervical screening)? Cervical cancer screening tests are usually needed 3 or 5 yearly for women 25-49 yrs and 5 yearly from 50-64 yrs, depending on where you live.

    YesNoI'm not sure

    We cannot treat you if you are not up-to-date with your smear tests. Please see your registered GP for further advice.

    We cannot treat you if you are not sure if you are up-to-date with your smear tests. Please see your registered GP for further advice.

    Do you already use any form of hormonal contraception (pill, patch, implant, coil, injection)?

    YesNoI'm not sure

    Please provide us with an up-to-date blood pressure reading (within the last 3 months). Your blood pressure must be normal before starting to take, and whilst taking, contraceptive pills for acne. You can purchase blood pressure monitors relatively cheaply from a supermarket or pharmacy.

    Systolic (the top number)Diastolic (the bottom number)

    55%

    Do you have any of the following?

    Irregular periods

    Unexplained vaginal bleeding or pain between periods

    Unexplained bleeding or pain after sex

    Your last period was late, lighter, shorter or unusual

    Other concerning symptoms

    I’m not sure

    Do you smoke?

    YesNoI'm not sure

    Please provide us with an up-to-date blood pressure reading (within the last 3 months). Your blood pressure must be normal before starting to take, and whilst taking, contraceptive pills for acne. You can purchase blood pressure monitors relatively cheaply from a supermarket or pharmacy.

    Systolic (the top number)Diastolic (the bottom number)

    66%

    Have you or a first degree relative ever had any of the following?

    Blood clots e.g. DVT(Deep vein thrombosis), PE (Pulmonary embolism)

    Breast, ovarian, cervical, or uterine cancer

    None of the above

    I’m not sure

    Have you ever had any of the following?

    Migraines with aura (aura are visual disturbances or tingling in the hands, arms or face)

    Heart disease including heart attack, angina, abnormal heart rhythm, heart failure

    Stroke or mini stroke (TIA)

    Recent Surgery in the last 3 months

    I am immobile e.g. in a wheelchair or bed bound

    HIV

    Epilepsy

    Diabetes

    High blood pressure

    High cholesterol or fats

    Disease of the gallbladder or liver

    Kidney disease

    Lupus or porphyria

    Sickle cell disease

    Inflammatory bowel disease (Crohn's disease or ulcerative colitis)

    None of the above

    I’m not sure

    Are you concerned about your safety or well-being at the moment? You can answer yes if you feel vulnerable or are being forced into obtaining treatment.

    YesNoI'm not sure

    If we don’t hear from you soon our team will reach out to you to check on your welfare. You can get help by emailing us at [email protected]. In an emergency you can contact the police.

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

    NoYes

    77%

    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.

    Upload Photo 1





    Add another photo

    Upload Photo 2





    Add another photo

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    88%

    Do you understand and agree with the following?

    No contraceptive is 100% effective at preventing pregnancy.

    With combined oral contraception pills, there is a low risk of serious side effects such as cervical cancer, breast cancer, and blood clots.

    If using Dianette, you understand that it is not designed for use solely as a contraceptive and you must be suffering with acne for the benefits to outweigh the risks of taking it. It should only be used for 3-4 cycles and stopped after your acne has cleared up. There is a higher risk of blood clots with Dianette than with other low dose combined oral contraceptive pills and it should not be used if you or a close family member have had blood clots without a known cause, or if you currently have any blood clotting problems.

    This medication will not provide protection against sexually transmitted infections (STIs)

    You should take your pill at the same time each day and if you miss a pill you may be at risk of pregnancy if you are sexually active- in this case you should seek advice from a healthcare professional

    You can take the pill either by having a 1 week break every month, or continuously for 3 months with a 4-7 day break- the latter is called ‘tricycling’. If using the tricycling routine you accept and understand that this is an 'off label' use This means it is not the standard way the pill is prescribed, and while it may be recommended by a healthcare professional for specific reasons, it carries potential risks and side effects that may differ from the usual use.

    Your pill may not work as well if you vomit or have severe diarrhoea

    You will ensure that you have regular blood pressure checks with your GP. Your blood pressure should be checked before you start any contraception, and annually thereafter.

    Long-acting contraceptives such as the injection, implant, and coil are generally considered more effective in preventing pregnancy and these are available if preferred by talking to your registered NHS GP. More information on alternative forms of contraception and risks versus benefits of each method at www.contraceptivechoices.org.

    You are aware that most acne treatments take 8-12 weeks to work and if there is no improvement after 3 months then you should contact a healthcare professional to review treatment.

    You are aware that if you have or develop severe scarring or psychological distress then you should see your GP as soon as possible.

    You confirm you are not currently pregnant.

    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 agree that if needed, a DigiDerm clinician may contact you via email, whatsapp 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.

    100%

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