Rosacea Assessment Form – Workspace Tabi Health

Name

First

Last

Parent or guardian name if applicable

First

Last

Have you had a serious reaction or intolerable side effects to brimonidine tartrate or any other medications before?

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

Are you breast feeding?

Do you have any kidney problems?

Do you have any heart problems?

Do you have any allergies?

Do you have any of the following symptoms?

Eye pain
Blurred vision
Sensitivity to light

Do you commonly experience redness of the face?

Has your doctor told you that you have rosacea?

Do you have eczema, broken skin or sunburn on the face?

Are you undergoing or have you recently undergone any of the following procedures?

Do you have any of the following?

Depression
Decreased blood flow to the brain or heart
Fall in blood pressure or standing up
Decreased bloood flow to the hands or feet
Sjogren’s syndrome

Please provide details of any symptoms you are experiencing (e.g. spider veins)

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 be 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.

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