Psoriasis Assessment

12/08/2024 21/08/2024

To ensure you are provided with the most effective treatment by our healthcare professional please answer the questions honestly and accurately. The questionnaire should only take approximately 3 minutes to complete.

If you are unsure about any of the questions, please call us on 0115 8501944 or email us at [email protected]

About You

1. Hi. What is your name?

2. Are you purchasing this medications for yourself

Yes No

3. Are you over 18 years?

Yes No

3b. Please advise further.

4. Are you breast feeding or pregnant or planning to become pregnant

Yes No

4b. Please provide more details.

5. Do you smoke?

Yes No

5b. Would you like information on stopping smoking?

Yes No

6. Do you drink alcohol?

Yes No

6b. Would you like information on safe alcohol use?

Yes No

7. Are you overweight?

Yes No

7b. Would you like information on weight management?

Yes No

Medical History

8. Which part of the body would you like to treat?

9. Have you been diagnosed of eczema or psoriasis before by a doctor?

Yes No

9b. How long have you suffered with eczema/psoriasis?

First time

<1yr

2-5yrs

>5 years

10. Does the condition get better after treatment

Yes No

10b. Please provide more details about why you think you suffer from Eczema/Psoriasis - You must provide this information

11. Is this flare up of eczema/psoriasis different to what you have experienced before?

Yes No

11b. Please provide more information- You must provide this information

12. Have you used any other creams/ointment to treat your skin condition?

Yes No

12b. Please provide more information - You must provide this information

13. Are you experiencing any of the following

Dry and itchy skin

Redness

Fluid filled vesicles

Scaling

Crusting of the skin

None

15. We strongly recommend that you upload a picture of the location of your skin condition to help our prescribers make an informed prescribing decision safely. Especially if:

You have not been diagnosed of eczema/dermatitis/psoriasis before
You have never used any treatments (steroids or moisturisers) before
You are ordering an antibiotic such as FUCIDIN, FUCIDIN H or FUCIBET
You are suffering from a new, worsening, or unfamiliar rash

Upload Image

Past Medical History

16. Do you have any other medical conditions (e.g. cancer) or past surgical procedures (e.g. splenectomy)?

Yes No

16b. Please provide more details - You must provide this information

17. Are you currently taking or recently stopped taking any prescription medicines, over-the-counter medicines, herbal medicines or recreational drugs?

Yes No

17b. Please provide more details - You must provide this information

18. Are you allergic to any medicines or other substances e.g. peanuts or soya

Yes No

18b. Please provide more details - You must provide this information

19. Would you like us to contact your GP?

Yes No

19b. Select your GP

Start Typing and your Practice will appear here

Unable to find your surgery? Click Here

20. Do you agree with the following?

You will NOT use any of the treatments on your face, neck, groin or genitals.

You will see your GP if your condition worsens, or does not respond to treatment in 7 days

You have read the information available on the treatments and medication web page and understand the side effects, their effectiveness and alternatives available.

I will contact my GP if I experience no relief after 14 days or your symptoms persist after 28 days of treatment.

You have answered the questions honestly and accurately and the treatment is solely for your personal use.

You will read and understand the patient information leaflet supplied with your medication.

You understand that although it is not compulsory, it is important to inform your GP of this treatment so they can provide safe healthcare.

You understand that prescribing decisions will be based on the answers to your consultations, and incorrect information can cause harm to your health. Orders may be rejected if not clinically suitable.

You are aware The Family Chemist will undertake a soft check to validate your identity using LexisNexis. Note: This does not affect your credit rating.

You have read and agree to our Terms and Conditions, Terms of Use and Privacy Policy.

Yes No

20b. We cannot supply you with this treatment at the moment. Please contact our patient support team at [email protected] so we can talk through your options.

Yes No

21. I confirm that I have read the information in this questionnaire and will follow the advice from the patient information leaflet before using the provided treatments.

Yes

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Medical History

Past Medical History

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