Thrush Assessment – Walk IN

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Step 1 of 2
Name
Do you suffer from severe or recurrent infection?
Do you have diabetes?
Do you have infection of the nails, scalp or genitals?
Are you pregnant, planning pregnancy, or is there any possibility that you could be pregnant?
Are you breast-feeding?
Do you have infection of the nails, scalp or genitals?
Do you have any allergies?
Are you immunosuppressed through disease or treatment?
Do you have any other skin problems?
Have you had a serious reaction or intolerable side effects to clotrimazole (Canesten®), miconazole nitrate, hydrocortisone or any other medications before?
Have you received treatment for thrush or candidal skin infection previously?
Do you have anaemia?
Are the infected areas itchy or inflamed?

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Do you suffer from severe or recurrent infection with thrush?
Do you have infection of the nails, scalp, or anywhere else on the body?
Are you worried that you may have a sexually transmitted infection (STI)?
Have you recently used antibiotics?
Do you have any of the symptoms listed below?

Start Assessment

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Step 1 of 3
Patient Name
Parent or guardian name if applicable
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?