Condition Questions
General Health Questions
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Terms & Conditions
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IMPORTANT
We do not treat suspected skin cancers, moles, growths, lumps, or infected wounds.
Any recommended treatments are paid for in addition to the consultation fee (£55).
This form should take you less than 5 minutes.
A clinician will reply ASAP (usually within 24 hours).
Please tell us about the problem in a couple of sentences.
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
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
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
Do you have any of the following symptoms?
Skin Appearance or ChangesSensory SymptomsHair ChangesNail ChangesMouth, Lips & Tongue ChangesEye SymptomsOther 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
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
Other Symptoms
OtherI don’t know
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
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?
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
I don’t knowNone of the above
Does anything make the problem better?
HeatColdExerciseSunlightSea water
Supplements
Certain supplements
Products
Certain products e.g. shampoos, cosmetics, toothpastes, mouthwashes
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:
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 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
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
None - I haven't tried any treatments.
What is your biological sex?
FemaleMaleTrans Female (Male at birth)Trans Male (Female at birth)Other
Are you pregnant, breastfeeding or trying for a baby?
YesNo
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?
Aneamia
Anxiety Disorder
Asthma
Atrial Fibrillation (AF)
Bipolar Disorder
Cancer (Past or Present)
Cholecystitis
COPD
Crohns
Depression
Eczema
Epilepsy
Folic acid deficiency
Gastric Reflux Disease
Gastric Sleeve
Hay Fever
Heart Arrhythmia
Heart Disease/ Heart Attack
Heart Failure
High Blood Pressure
High Cholesterol
Inflammatory Bowel Disease
Iron deficiency
Irritable Bowel Syndrome (IBS)
Kidney Disease
Liver Disease
Migraine
Myasthenia Gravis
Obsessive-Compulsive Disorder
Osteoarthritis
Osteoporosis
Pancreatitis
Peripheral Vascular Disease
Psoriasis
Raynaud’s
Rheumatoid Arthritis
Schizophrenia
Sjorgen’s syndrome
Stroke/ TIA
Surgery
Thyroid Disorders
Type 1 Diabetes
Type 2 Diabetes
Ulcerative Colitis
Vitamin D deficiency
None of the above
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?
No
Medications
Over the counter medications/ herbal medications
Recreational drugs
Vaccines
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?
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?
Please upload at least one photo of your problem (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.
Body Part: Additional Information (Optional):
Add another photo
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?
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 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 below.
I confirm that I have read, understand, agree, and accept the above information and the Terms and Conditions, Privacy Policy, and Patient Consent Form for DigiDerm’s Services.
