Dermatitis Assessment Form – Workspace Tabi Health

Name

First

Last

Parent or guardian name if applicable

First

Last

Do you have eczema or psoriasis?

Women only: Are you pregnant, or is there any possibility that you could be pregnant?

Have you ever had an allergic (hypersensitive) reaction to betamethasone valerate or any other steroid creams?

Women only: Are you breast-feeding or planning on breast-feeding?

Do you have any allergies?

Do you get eczema or psoriasis on your face or eyes?

Are you or are you going to be applying the cream under an airtight dressing?

Do you have chronic leg ulcers?

Do you have eczema or psoriasis on a large area of your body?

Have you ever suffered from blurred vison whilst receiving systemic and topical corticosteroids?

Do you have eczema or psoriasis on broken skin or within skin folds?

Do you have any of the following?

Do you have any untreated bacterial, fungal or viral skin lesions?

Do you have persistent eczema or hand eczema?

Do you have liver or kidney problems?

Please list your symptoms below

Please list all your current prescription medication including any medication you buy over the counter

Please provide details of any recent or past medical history of note (e.g. previous conditions that you have been treated for)

Complete Patient Details

Patients Name

First

Last

Layout

Date of Birth (DD/MM/YYYY)

Age

Phone

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

GPs Name & Address

Patient Consent

I agree that my Summary Care Records willl accessed to confirm medication history with the GP.
I agree that my GP will be notified about this cosultation

Patient ID

I will have available proof of ID (such as passport, drivers license or photocard) during consultation.

Signature (Type full name of patient, parent or guardian)

Name

First

Last

Patient Name

First

Last

Parent or guardian name if applicable

First

Last

Have you had a serious reaction to any acne treatments before?

Do you have any allergies?

Are you pregnant, planning pregnancy, or is there any possibility that you could be pregnant? (copy)

Are you breast feeding?

Have you started puberty?

Are you willing to use contraception for at least 1 month before starting treatment, during treatment, and for at least 1 month after stopping treatment?

Do you have perioral dermatitis (redness and soreness around your mouth) or rosacea?

Are you currently using any other treatments for acne?

Have you recently received an acne treatment containing antibiotics?

If you have used acne treatments before, did you experience any side effects or skin irritation?

Do you have a history of photo-allergy (skin reactions in the sunlight)?

Do you have, or have you had any of the following? ̵ Regional enteritis (crohn's disease) ̵ Ulcerative colitis (inflamed colon and rectum) ̵ Inflammatory bowel disease or antibiotic-associated colitis (including pseudomembranous colitis)

Have you or any of your close family had skin cancer?

Do you currently have sunburn, broken skin or abraded skin?

Do you have any allergic diseases such as asthma, eczema or rhinitis?

Do you have any liver or kidney problems?

Are you currently using any cosmetics, medicated cleansers or scrubbing solutions?

Do you suffer from severe psychological distress because of your acne?

Have you undergone or recently undergone procedures such as depilation, chemical hair treatments, chemical peels, dermabrasion, laser resurfacing of the skin or phototherapy?

Are you sensitive to sunlight or do you have considerable sun exposure?

Please list all your current prescription medication including any medication you buy over the counter

Please provide details of any recent or past medical history of note (e.g. other conditions you have been treated for)

Complete Patient Details

Patients Name

First

Last

Date of Birth (DD/MM/YYYY)

Phone

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

GPs Name & Address

Patient GP Consent

I am happy to share details of this consultation with my GP.
I DO NOT want to share details of this consultation with my GP.

Patient Consent (Other)

I am happy to access treatment from Tabi Health Clinic and not from my GP
I have read the Pharmadoctor terms and conditions
I have answered the questions above honestly

Click to view pharmadoctor terms & conditions.

Patient ID

I will have available proof of ID (such as passport, drivers license or photocard) during consultation.

Choose type of consultation required

Walk In (done in the clinic, based in Hitchin SG4 9TH)
Online (via video consultation)

Complete Patient Details

Start Assessment

Complete Patient Details