1234567891011121314151/15WebsiteFirst NameLast NameEmailDigiDerm | Online Skin Doctor Express Consultation Service Important Information: - This questionnaire should take about 5-10 minutes to complete. Once you have finished, one of our clinicians will get back to you via Email or WhatsApp within 24-48 hours with a diagnosis and treatment advice. Please check your junk email folder just in case. Please note: We do not advise on suspected skin cancers, moles, growths, lumps, or wounds. We do not currently prescribe Roaccutane (Isotretinoin) for Acne. This consultation does not include the cost of any prescription medications or treatments. If the clinician recommends any treatments then you can purchase these afterwards via your account (no obligation). We send all medications via Royal Mail next day tracked delivery. You can read the FAQ section for more information. Let's get started... Please tell us about the problem in a couple of sentences. Where on your body is the problem? Please select all that apply. Head and Neck FaceScalpEyebrowsEyelidsEye lashesEarsMouthBeard areaNeck Upper Body ChestBreastsNipplesBackShouldersForearmsUpper ArmsArmpitsHandsFingersWristsStomach/AbdomenElbows Lower Body GroinButtocksThighsLower legsFeetToesAnklesKnees Hair and Nails Hair loss on the headFinger NailsToe Nails Other All overI'm not sureGenitals Face ForeheadBoth CheeksLeft CheekRight CheekNoseJaw lineChinCentre of face (down the middle) Chest Entire chestLeft sideRight sideIn Between Breasts Stomach/Abdomen StomachLower AbdomenBelly ButtonAll over Breasts Underneath both breasts (in the skin folds)Underneath one breast (in the skin fold)Side(s)TopBottomIn between breasts Nipples BothLeftRight Back UpperMiddleLowerAll over Shoulders BothLeftRight Feet TopSideSole (underneath)HeelLeft footRight footBoth feet Toes TopBottomSideToe webs (skin folds)Big toe2nd toeMiddle toe4th toeLittle toeLeft footRight footBoth feet Fingers TopBottomSideFinger webs (skin folds)ThumbIndex fingerMiddle fingerRing fingerLittle fingerLeft handRight handBoth hands Hands TopPalmLeft handRight handBoth hands Wrists TopInsideAll aroundLeft wristRight wristBoth wrists Ankles Front/TopBackSideAll around ankleLeft ankleRight ankleBoth ankles Finger Nails ThumbIndex fingerMiddle fingerRing fingerLittle fingerLeft handRight handBoth hands Toe Nails Big toe2nd toeMiddle toe4th toeLittle toeLeft footRight footBoth feet Scalp All over scalpFrontBackSidesNape (back of neck where hair starts)Several PatchesOne Patches Eyebrows BothLeftRightSingle patchMultiple patchesAll over Eyelids All overPatchSingle spotSingle spotLeft eyelidRight eyelidBoth eyelids Eye lashes Multiple lashesSingle lashLeft eyeRight eyeBoth eyes Ears Outside earInside earEar canalBehind earEar lobeLeft earRight earBoth ears Mouth Around the mouthCorner(s) of mouthRoof of mouthInside cheeksGumsTongueUnder tongueBottom lipTop lipBoth lips Beard area All overSeveral PatchesOne patch Neck CollarFrontBackLeft sideRight sideAll around Hair loss on the head Over the crown (topmost part of your scalp towards the back of your head)Top of the headFrontal hairline (including receeding hairline)Sides of your headGeneral thinning all over the scalpNape of the neck (where the hair starts at the back)Single patchMultiple patchesFront/ fringeBald spots with itching or burning Forearms InsideOutsideAll aroundLeft armRight armBoth arms Upper Arms InsideOutsideLeft armRight armBoth arms Armpits Left armpitRight armpitBoth armpits Lower legs CalfShinLeft legRight legBoth legs Thighs Left thighRight thighBoth thighs Groin Left groinRight groinBoth groins Buttocks Butt CheeksBum fold (skin fold)Anus Elbows Inside elbow foldOutside elbow surfaceLeftRight Knees Behind KneesOutside knee surfaceLeftRight Genitals Due to the sensitive nature of this area- DigiDerm does not treat skin problems related to the genitals. Please visit your NHS GP or local sexual health clinic. All over I'm not sure Next0% Is it getting worse? NoYesI don’t knowOther When did the problem first start? How quickly did the problem start? Suddenly (minutes)Quickly (hours)Gradually (days)Slowly (weeks)Very slowly (months)Over several yearsOtherI don't know BackNext7% 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 experienced this problem before? NoYesI don’t know Please explain, e.g., When did you last experience it? Is it the same as before or different now? BackNext14% Do you have any of the following symptoms? Skin Appearance or Changes RednessRoughSmoothDryOilyCrackingBleedingWhiteheadsBlackheadsSmall firm spots (papules)Small pus filled spots (pustules)Cysts, bumps and lumpinessScarringBlisteringCrustingScaling (Flakey skin)Darkening of skin (increase in colour or pigment)Lightening of skin (loss of colour or pigment)SwellingExcessive SweatThickened skinConsistency has changedRegular infections Sensory Symptoms ItchTinglingDischarge or OozingPain or sensitivityStinging or BurningWarm to touch or hot skinCold skinFeeling of TightnessAltered sensation or feelingNumbness/Loss of sensation or feeling Please rate your pain or sensitivity on a scale of 1 to 10, where 0 means no pain and 10 means the worst pain imaginable: 12345678910 Hair Changes Excessive hair growthHair lossChange in hair colourChange in hair texture or straightness Nail Changes Change in nail colourBrittle nail(s)Pits (small holes) in nailsWhite lines on nailsCurving of nails the wrong way (spoon shaped)Nail breakdown/ lossBad smell (malodour) Mouth, Lips & Tongue Changes Cold SoresDry mouthCrackingBad smell (malodour)RoughnessBleedingDiscolourationWhite spots/film Eye Symptoms GrittinessDrynessPainIrritationSensitivity to lightBloodshotDischargeBlurred vision Please rate your eye pain on a scale of 1 to 10, where 0 means no pain and 10 means the worst pain imaginable: 12345678910 Other Symptoms OtherI don’t know Please explain: BackNext21% Have you been unwell in any other way recently? Do you have any of the following concerning symptoms? No- I have been feeling well apart from my skin problemI have been unwell recently due to another condition, illness or circumstanceTemperatureFeverNauseaVomitingNight sweatsWeight lossExcessive tirednessJoint pain/ swelling Please tell us more about the other condition, illness, or circumstance: 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 excessive tiredness: Please tell us more about your joint pain or swelling: BackNext28% Does anything make the problem worse? Environmental Factors HeatColdSunlightDustPetsPollen/Grass/Flowers/TreesWater Lifestyle and Diet StressAlcoholExerciseSweatingSpicy foodsCaffeineFood Products and Chemicals Chemicals e.g. toothpastes, mouthwashes, washing powders, hair dyes, makeup Hair treatments e.g. keratin treatments, chemical relaxers, hot-combing Hair styles e.g. weaves, ponytails, braids, buns, shaving Clothing Certain clothes/ fabrics Other Factors Other I don’t knowNone of the above BackNext35% Does anything make the problem better? Environmental Factors HeatColdExerciseSunlightSea water Supplements Certain supplements Products Certain products e.g. shampoos, cosmetics, toothpastes, mouthwashes Other Factors Other I don’t knowNone of the above BackNext42% Have you started any new medications around the same time that this skin problem started? e.g. any prescription, over the counter or herbal medications/ supplements No Yes I don't know Have other people in your family suffered with this skin problem too, or do you have a personal or family history of autoimmune diseases? e.g. Lupus, Scleroderma, Pemphigus, Vitiligo, Lichen Planus, Sjogren’s, Rheumatoid Arthritis, Crohn’s Disease NoYes, other people in my family have suffered with this skin problem tooYes, I have a personal or family history of autoimmune diseaseI don’t know Have you tried to get help for this problem before? NoYes- I have seen a healthcare professional e.g. GP, Dermatologist, Pharmacist, NurseYes- I have seen a Cosmetic specialist / Aesthetic practitioner/ BeauticianOther BackNext50% Have you already tried any of the following treatments? Antibiotic tablets/capsules e.g. Lymecycline, Erythromycin, Flucloxacillin Antibiotic creams/ gels/ lotions e.g. Zineryt, Metronidazole, Clindamycin, Fucidin, Fucibet Steroid creams/ointments e.g. Hydrocortisone, Eumovate, Elocon, Betnovate, Fucibet Antifungal Creams/ Tablets e.g. Canesten, Daktarin, Daktacort, Terbinafine tablets, Itraconazole capsules Antiviral Creams/ Tablets e.g. Zovirax, Aciclovir tablets Retinoid creams/ gels e.g. Differin, Epiduo, Isotrex, Treclin, Aklief Azelaic acid creams/gels e.g. Skinoren, Finacea Benzoyl Peroxide gels/ creams/lotions/washes e.g. Acnecide gel, Clean and Clear Washes/ Cleansers/ Soap Substitutes e.g. Dermol, Cetaphil, Cerave Moisturisers e.g. Cetraben cream/ointment, Diprobase, E45, Doublebase Scalp Applications e.g. Betnovate, Enstillar, Dovobet Shampoos e.g. Capasal, Dermax, Polytar, Alphosyl, Etrivex, Nizoral Steroid tablets or injections Antihistamines e.g. Loratadine, Cetirizine, Fexofenadine Specialist Acne treatments e.g. Epiduo, Treclin, Aklief, Spironolactone, Isotretinoin, Dianette contraceptive pill Specialist Eczema treatments e.g. Protopic or Elidel Creams/Ointments Specialist Rosacea treatments e.g. Soolantra, Mirvaso Specialist Psoriasis treatments e.g. Dovonex, Dovobet, Enstillar Specialist Hair treatments e.g. Regaine, Finasteride/Dutasteride, PRP, Hair transplant, Wigs/hair pieces Mouth products e.g Cold sore treatments, Mouthwashes, Lip balms, Throat sprays, Artificial saliva 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/ Alternative treatments Surgical Procedures Other None - I haven't tried any treatments. BackNext57% Have you ever had any of these tests to help diagnose your skin problem? NoneSwabBlood testsNail clippings/scrapingsAllergy tests e.g. skin prick, patch test, blood testSkin biopsyOtherI’m not sure Do you suffer from any mental health conditions? e.g. depression, anxiety, OCD NoYesI don’t knowI would rather not say Does your skin problem affect your mental health? NoYes Do you think your mental health has a negative impact on your skin condition? NoYes BackNext64% Are you pregnant, breastfeeding or trying to have a baby? No/ Not applicablePregnantBreastfeedingTrying to have a baby How many weeks pregnant are you? Are you allergic to any of the following? Medications/ Supplements/ HerbsPeanutsSoyaOther substance/ materialOtherNone Please name the product(s) and explain what happens when you have an allergic reaction? What symptoms do you get? What happens when you have an allergy? What symptoms do you get? What happens when you have an allergy? What symptoms do you get? Please name the substance/material and explain what happens when you have an allergic reaction? What symptoms do you get? Please name the allergen and describe what happens when you have the reaction. BackNext71% Have you been diagnosed with any of the following medical conditions? Anaemia Anxiety Disorder Asthma Atrial Fibrillation (AF) Bipolar Disorder Cancer (Past or Present) COPD Depression Eczema Epilepsy Thyroid Disorders Type 1 Diabetes Folic acid deficiency Gastric Reflux Disease Hay fever Heart Disease/ Heart Attack Heart Failure High Cholesterol High Blood Pressure Inflammatory Bowel Disease Iron deficiency Irritable Bowel Syndrome (IBS) Type 2 Diabetes Vitamin D deficiency Kidney Disease Liver Disease Migraine Obsessive-Compulsive Disorder Osteoarthritis Osteoporosis Psoriasis Rheumatoid Arthritis Schizophrenia Stroke/ TIA Surgical History (e.g. previous surgeries) Other None Please provide details about your cancer diagnosis: Please provide details of your surgical history: Please provide details of any other conditions: BackNext78% Are you currently taking any medications? (this includes prescription only medications, over the counter medications and/or any herbal/homeopathic remedies) NoYes Please list the medications you are currently taking: BackNext85% Photo Upload You can upload up to 6 photos of the affected area(s). Use a phone or digital camera. For phones, use the main camera, not the "selfie" camera. Ask someone to help you take the photos for better quality. Ensure the lens is clean and take the photo in a well-lit area with natural light, but avoid direct sunlight. Avoid shadows on the skin. Use a plain background (such as a plain towel, sheet or wall). 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. Focus is key. If the lesion is raised, take a sideways photo to highlight the elevation. Include a size reference (e.g., a coin or ruler) in your photo for scale. Take multiple photos and send only the best ones where the skin problem is clear and in focus. Upload Photo 1 Body Part: Additional Information (Optional): Add another photo Upload Photo 2 Body Part: Additional Information (Optional): Add another photo Upload Photo 3 Body Part: Additional Information (Optional): Add another photo Upload Photo 4 Body Part: Additional Information (Optional): Add another photo Upload Photo 5 Body Part: Additional Information (Optional): Add another photo Upload Photo 6 Body Part: Additional Information (Optional): BackNext92% How did you hear about us? GoogleInstagramTikTokYouTubeFacebookRedditWord of mouthLeaflet/ PosterNewspaper/ MagazineTVRadioOther Please tell us more: Would you like to sign up to our monthly newsletter? YesNo Terms and Conditions I confirm that I have read and accept the Terms and Conditions. By accepting these terms and conditions, you agree to read the Patient Information Leaflet of any medications or products recommended and/or prescribed and will not take the medication or product if you're allergic to any of its ingredients or if it is contraindicated for you to use. If in doubt, please contact the prescriber. You agree that a DigiDerm clinician can 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. 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 a more appropriate place for you to get help. There is no obligation to purchase any products or medications. You accept that there is no obligation for a DigiDerm clinician to prescribe a medication if it is deemed to be clinically inappropriate. You acknowledge that any information received from this form, including photos, is stored securely and confidentially by DigiDerm as per our Terms and Conditions. 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. You confirm that you are at least 16 years old and resident in the UK at the time of the consultation. You confirm that you have read, understood and accepted our Patient Consent Form as found in our Terms and Conditions. [stripe* stripe-85 "Make Payment"] Finish & Proceed to Payment Back100% 1234567891011121314151/15WebsiteFirst NameLast NameEmailDigiDerm | Online Skin Doctor Express Consultation Service Important Information: – This questionnaire should take about 5-10 minutes to complete. Once you have finished, one of our clinicians will get back to you via Email or WhatsApp within 24-48 hours with a diagnosis and treatment advice. Please check your junk email folder just in case. Please note: We do not advise on suspected skin cancers, moles, growths, lumps, or wounds. We do not currently prescribe Roaccutane (Isotretinoin) for Acne. This consultation does not include the cost of any prescription medications or treatments. If the clinician recommends any treatments then you can purchase these afterwards via your account (no obligation). We send all medications via Royal Mail next day tracked delivery. You can read the FAQ section for more information. Let’s get started… Please tell us about the problem in a couple of sentences. Where on your body is the problem? Please select all that apply. Head and Neck FaceScalpEyebrowsEyelidsEye lashesEarsMouthBeard areaNeck Upper Body ChestBreastsNipplesBackShouldersForearmsUpper ArmsArmpitsHandsFingersWristsStomach/AbdomenElbows Lower Body GroinButtocksThighsLower legsFeetToesAnklesKnees Hair and Nails Hair loss on the headFinger NailsToe Nails Other All overI'm not sureGenitals Face ForeheadBoth CheeksLeft CheekRight CheekNoseJaw lineChinCentre of face (down the middle) Chest Entire chestLeft sideRight sideIn Between Breasts Stomach/Abdomen StomachLower AbdomenBelly ButtonAll over Breasts Underneath both breasts (in the skin folds)Underneath one breast (in the skin fold)Side(s)TopBottomIn between breasts Nipples BothLeftRight Back UpperMiddleLowerAll over Shoulders BothLeftRight Feet TopSideSole (underneath)HeelLeft footRight footBoth feet Toes TopBottomSideToe webs (skin folds)Big toe2nd toeMiddle toe4th toeLittle toeLeft footRight footBoth feet Fingers TopBottomSideFinger webs (skin folds)ThumbIndex fingerMiddle fingerRing fingerLittle fingerLeft handRight handBoth hands Hands TopPalmLeft handRight handBoth hands Wrists TopInsideAll aroundLeft wristRight wristBoth wrists Ankles Front/TopBackSideAll around ankleLeft ankleRight ankleBoth ankles Finger Nails ThumbIndex fingerMiddle fingerRing fingerLittle fingerLeft handRight handBoth hands Toe Nails Big toe2nd toeMiddle toe4th toeLittle toeLeft footRight footBoth feet Scalp All over scalpFrontBackSidesNape (back of neck where hair starts)Several PatchesOne Patches Eyebrows BothLeftRightSingle patchMultiple patchesAll over Eyelids All overPatchSingle spotSingle spotLeft eyelidRight eyelidBoth eyelids Eye lashes Multiple lashesSingle lashLeft eyeRight eyeBoth eyes Ears Outside earInside earEar canalBehind earEar lobeLeft earRight earBoth ears Mouth Around the mouthCorner(s) of mouthRoof of mouthInside cheeksGumsTongueUnder tongueBottom lipTop lipBoth lips Beard area All overSeveral PatchesOne patch Neck CollarFrontBackLeft sideRight sideAll around Hair loss on the head Over the crown (topmost part of your scalp towards the back of your head)Top of the headFrontal hairline (including receeding hairline)Sides of your headGeneral thinning all over the scalpNape of the neck (where the hair starts at the back)Single patchMultiple patchesFront/ fringeBald spots with itching or burning Forearms InsideOutsideAll aroundLeft armRight armBoth arms Upper Arms InsideOutsideLeft armRight armBoth arms Armpits Left armpitRight armpitBoth armpits Lower legs CalfShinLeft legRight legBoth legs Thighs Left thighRight thighBoth thighs Groin Left groinRight groinBoth groins Buttocks Butt CheeksBum fold (skin fold)Anus Elbows Inside elbow foldOutside elbow surfaceLeftRight Knees Behind KneesOutside knee surfaceLeftRight Genitals Due to the sensitive nature of this area- DigiDerm does not treat skin problems related to the genitals. Please visit your NHS GP or local sexual health clinic. All over I’m not sure Next0% Is it getting worse? NoYesI don’t knowOther When did the problem first start? How quickly did the problem start? Suddenly (minutes)Quickly (hours)Gradually (days)Slowly (weeks)Very slowly (months)Over several yearsOtherI don't know BackNext7% 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 experienced this problem before? NoYesI don’t know Please explain, e.g., When did you last experience it? Is it the same as before or different now? BackNext14% Do you have any of the following symptoms? Skin Appearance or Changes RednessRoughSmoothDryOilyCrackingBleedingWhiteheadsBlackheadsSmall firm spots (papules)Small pus filled spots (pustules)Cysts, bumps and lumpinessScarringBlisteringCrustingScaling (Flakey skin)Darkening of skin (increase in colour or pigment)Lightening of skin (loss of colour or pigment)SwellingExcessive SweatThickened skinConsistency has changedRegular infections Sensory Symptoms ItchTinglingDischarge or OozingPain or sensitivityStinging or BurningWarm to touch or hot skinCold skinFeeling of TightnessAltered sensation or feelingNumbness/Loss of sensation or feeling Please rate your pain or sensitivity on a scale of 1 to 10, where 0 means no pain and 10 means the worst pain imaginable: 12345678910 Hair Changes Excessive hair growthHair lossChange in hair colourChange in hair texture or straightness Nail Changes Change in nail colourBrittle nail(s)Pits (small holes) in nailsWhite lines on nailsCurving of nails the wrong way (spoon shaped)Nail breakdown/ lossBad smell (malodour) Mouth, Lips & Tongue Changes Cold SoresDry mouthCrackingBad smell (malodour)RoughnessBleedingDiscolourationWhite spots/film Eye Symptoms GrittinessDrynessPainIrritationSensitivity to lightBloodshotDischargeBlurred vision Please rate your eye pain on a scale of 1 to 10, where 0 means no pain and 10 means the worst pain imaginable: 12345678910 Other Symptoms OtherI don’t know Please explain: BackNext21% Have you been unwell in any other way recently? Do you have any of the following concerning symptoms? No- I have been feeling well apart from my skin problemI have been unwell recently due to another condition, illness or circumstanceTemperatureFeverNauseaVomitingNight sweatsWeight lossExcessive tirednessJoint pain/ swelling Please tell us more about the other condition, illness, or circumstance: 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 excessive tiredness: Please tell us more about your joint pain or swelling: BackNext28% Does anything make the problem worse? Environmental Factors HeatColdSunlightDustPetsPollen/Grass/Flowers/TreesWater Lifestyle and Diet StressAlcoholExerciseSweatingSpicy foodsCaffeineFood Products and Chemicals Chemicals e.g. toothpastes, mouthwashes, washing powders, hair dyes, makeup Hair treatments e.g. keratin treatments, chemical relaxers, hot-combing Hair styles e.g. weaves, ponytails, braids, buns, shaving Clothing Certain clothes/ fabrics Other Factors Other I don’t knowNone of the above BackNext35% Does anything make the problem better? Environmental Factors HeatColdExerciseSunlightSea water Supplements Certain supplements Products Certain products e.g. shampoos, cosmetics, toothpastes, mouthwashes Other Factors Other I don’t knowNone of the above BackNext42% Have you started any new medications around the same time that this skin problem started? e.g. any prescription, over the counter or herbal medications/ supplements No Yes I don't know Have other people in your family suffered with this skin problem too, or do you have a personal or family history of autoimmune diseases? e.g. Lupus, Scleroderma, Pemphigus, Vitiligo, Lichen Planus, Sjogren’s, Rheumatoid Arthritis, Crohn’s Disease NoYes, other people in my family have suffered with this skin problem tooYes, I have a personal or family history of autoimmune diseaseI don’t know Have you tried to get help for this problem before? NoYes- I have seen a healthcare professional e.g. GP, Dermatologist, Pharmacist, NurseYes- I have seen a Cosmetic specialist / Aesthetic practitioner/ BeauticianOther BackNext50% Have you already tried any of the following treatments? Antibiotic tablets/capsules e.g. Lymecycline, Erythromycin, Flucloxacillin Antibiotic creams/ gels/ lotions e.g. Zineryt, Metronidazole, Clindamycin, Fucidin, Fucibet Steroid creams/ointments e.g. Hydrocortisone, Eumovate, Elocon, Betnovate, Fucibet Antifungal Creams/ Tablets e.g. Canesten, Daktarin, Daktacort, Terbinafine tablets, Itraconazole capsules Antiviral Creams/ Tablets e.g. Zovirax, Aciclovir tablets Retinoid creams/ gels e.g. Differin, Epiduo, Isotrex, Treclin, Aklief Azelaic acid creams/gels e.g. Skinoren, Finacea Benzoyl Peroxide gels/ creams/lotions/washes e.g. Acnecide gel, Clean and Clear Washes/ Cleansers/ Soap Substitutes e.g. Dermol, Cetaphil, Cerave Moisturisers e.g. Cetraben cream/ointment, Diprobase, E45, Doublebase Scalp Applications e.g. Betnovate, Enstillar, Dovobet Shampoos e.g. Capasal, Dermax, Polytar, Alphosyl, Etrivex, Nizoral Steroid tablets or injections Antihistamines e.g. Loratadine, Cetirizine, Fexofenadine Specialist Acne treatments e.g. Epiduo, Treclin, Aklief, Spironolactone, Isotretinoin, Dianette contraceptive pill Specialist Eczema treatments e.g. Protopic or Elidel Creams/Ointments Specialist Rosacea treatments e.g. Soolantra, Mirvaso Specialist Psoriasis treatments e.g. Dovonex, Dovobet, Enstillar Specialist Hair treatments e.g. Regaine, Finasteride/Dutasteride, PRP, Hair transplant, Wigs/hair pieces Mouth products e.g Cold sore treatments, Mouthwashes, Lip balms, Throat sprays, Artificial saliva 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/ Alternative treatments Surgical Procedures Other None – I haven't tried any treatments. BackNext57% Have you ever had any of these tests to help diagnose your skin problem? NoneSwabBlood testsNail clippings/scrapingsAllergy tests e.g. skin prick, patch test, blood testSkin biopsyOtherI’m not sure Do you suffer from any mental health conditions? e.g. depression, anxiety, OCD NoYesI don’t knowI would rather not say Does your skin problem affect your mental health? NoYes Do you think your mental health has a negative impact on your skin condition? NoYes BackNext64% Are you pregnant, breastfeeding or trying to have a baby? No/ Not applicablePregnantBreastfeedingTrying to have a baby How many weeks pregnant are you? Are you allergic to any of the following? Medications/ Supplements/ HerbsPeanutsSoyaOther substance/ materialOtherNone Please name the product(s) and explain what happens when you have an allergic reaction? What symptoms do you get? What happens when you have an allergy? What symptoms do you get? What happens when you have an allergy? What symptoms do you get? Please name the substance/material and explain what happens when you have an allergic reaction? What symptoms do you get? Please name the allergen and describe what happens when you have the reaction. BackNext71% Have you been diagnosed with any of the following medical conditions? Anaemia Anxiety Disorder Asthma Atrial Fibrillation (AF) Bipolar Disorder Cancer (Past or Present) COPD Depression Eczema Epilepsy Thyroid Disorders Type 1 Diabetes Folic acid deficiency Gastric Reflux Disease Hay fever Heart Disease/ Heart Attack Heart Failure High Cholesterol High Blood Pressure Inflammatory Bowel Disease Iron deficiency Irritable Bowel Syndrome (IBS) Type 2 Diabetes Vitamin D deficiency Kidney Disease Liver Disease Migraine Obsessive-Compulsive Disorder Osteoarthritis Osteoporosis Psoriasis Rheumatoid Arthritis Schizophrenia Stroke/ TIA Surgical History (e.g. previous surgeries) Other None Please provide details about your cancer diagnosis: Please provide details of your surgical history: Please provide details of any other conditions: BackNext78% Are you currently taking any medications? (this includes prescription only medications, over the counter medications and/or any herbal/homeopathic remedies) NoYes Please list the medications you are currently taking: BackNext85% Photo Upload You can upload up to 6 photos of the affected area(s). Use a phone or digital camera. For phones, use the main camera, not the “selfie” camera. Ask someone to help you take the photos for better quality. Ensure the lens is clean and take the photo in a well-lit area with natural light, but avoid direct sunlight. Avoid shadows on the skin. Use a plain background (such as a plain towel, sheet or wall). 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. Focus is key. If the lesion is raised, take a sideways photo to highlight the elevation. Include a size reference (e.g., a coin or ruler) in your photo for scale. Take multiple photos and send only the best ones where the skin problem is clear and in focus. Upload Photo 1 Body Part: Additional Information (Optional): Add another photo Upload Photo 2 Body Part: Additional Information (Optional): Add another photo Upload Photo 3 Body Part: Additional Information (Optional): Add another photo Upload Photo 4 Body Part: Additional Information (Optional): Add another photo Upload Photo 5 Body Part: Additional Information (Optional): Add another photo Upload Photo 6 Body Part: Additional Information (Optional): BackNext92% How did you hear about us? GoogleInstagramTikTokYouTubeFacebookRedditWord of mouthLeaflet/ PosterNewspaper/ MagazineTVRadioOther Please tell us more: Would you like to sign up to our monthly newsletter? YesNo Terms and Conditions I confirm that I have read and accept the Terms and Conditions. By accepting these terms and conditions, you agree to read the Patient Information Leaflet of any medications or products recommended and/or prescribed and will not take the medication or product if you’re allergic to any of its ingredients or if it is contraindicated for you to use. If in doubt, please contact the prescriber. You agree that a DigiDerm clinician can 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. 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 a more appropriate place for you to get help. There is no obligation to purchase any products or medications. You accept that there is no obligation for a DigiDerm clinician to prescribe a medication if it is deemed to be clinically inappropriate. You acknowledge that any information received from this form, including photos, is stored securely and confidentially by DigiDerm as per our Terms and Conditions. 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. You confirm that you are at least 16 years old and resident in the UK at the time of the consultation. You confirm that you have read, understood and accepted our Patient Consent Form as found in our Terms and Conditions. [stripe* stripe-85 “Make Payment”] Finish & Proceed to Payment Back100%
