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      Condition Questions

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      General Health Questions

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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

    Are you currently experiencing oral thrush (or what you think is oral thrush?)

    YesOther

    Do you suffer from recurrent oral thrush infections? (More than one case every 3 months)

    YesNoOther

    Do any of the following apply to you?

    You have a weakened immune system e.g. due to HIV, cancer treatments or medication that suppress the immune system You have recently had antibioticsYou wear denturesYou use a steroid containing inhalerYou are diabeticYou have a dry mouth due to a medical condition or medicationYou have recently undergone chemotherapy or radiotherapyYou smoke or use tobacco productsYou have had blood tests or other investigations for other health concerns recentlyNone of the aboveOther

    What symptoms do you have? Please select all that apply

    White patches inside the mouth that can be wiped offSore tongue or gumsAltered or unpleasant tasteCracks at the corners of the mouthSmooth, red patches that don’t wipe awayNone of the aboveOther

    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

    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:

    Does anything make it WORSE? Please select all that apply

    Smoking or using tobacco productsWearing dentures, especially if not properly cleanedTaking antibioticsUsing inhalers that contain steroidsPoor oral hygieneA weakened immune system e.g. due to illness or medications Stress or fatigueDiabetes (poorly controlled blood sugar)Certain foodsDrinking AlcoholMedicationsOtherNone of the aboveI don’t know

    Does anything make it BETTER? Please select all that apply

    Rinsing your mouth with warm salt waterMaintaining good oral hygiene (brushing and flossing)Cleaning and disinfecting dentures regularlyEating soft, bland foodsDrinking plenty of waterAvoiding spicy or acidic foodsStopping or reducing smoking/tobacco useReducing sugar intakeManaging underlying health conditions e.g. controlling blood sugar for diabetes OtherNone of the aboveI don’t know

    Have you already tried any of the following treatments?

    No - I haven't tried any treatments yet

    Mouthwashes
    e.g saltwater rinse, antiseptic mouthwash

    Antifungal gels
    e.g Miconazole (Daktarin) Oral Gel

    Antifungal tablets
    e.g Fluconazole

    Herbal/ Supplements/ Alternative treatments
    E.g clove oil, probiotics, apple cider vinegar

    Other

    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.

    Upload Photo 1




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

    You will read the patient information leaflet supplied with any medication we send you. 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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