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Weight Loss
Erectile Dysfunction
Hair Loss
Oral Contraception
Urinary Tract Infection
The Health Hub
Log In
Register

Eczema And Dermatitis Assessment

This questionnaire is a vital part of your consultation. Please provide accurate details about your current medications, medical history, and any other relevant information. Your honest responses help our prescribers recommend the most appropriate advice and treatment for your needs. Be sure to review all medical information before selecting your treatment.

1. Medical Questions

Have you experienced any medical issues or undergone any operations? Such as(Required)

Please pick one

Are you currently taking any medications, whether they are prescription, over-the-counter, or herbal supplements?(Required)

Yes

No

Do you have any allergies to medications or other substances?(Required)

Yes

No

Do you take any recreational drugs?(Required)

Yes

No

What is your blood pressure?(Required)

Do you drink Alcohol(Required)

Yes

No

Do you Smoke

Yes

No

Who diagnosed you with eczema/psoriasis?(Required)

Please pick one option

Where is you eczema/psoriasis located(Required)

Please pick one option

Please provide more information(Required)

Please list any treatments you've tried for your condition and if they were effective or not(Required)

We highly recommend uploading a picture of your skin condition to avoid delays in processing your order.

Uploading a picture of your eczema can be highly beneficial for us as it allows our specialists to accurately assess your condition and recommend the most effective treatment. This helps ensure that your order is processed quickly and accurately, preventing any delays

Drop files here or

Max. file size: 4 GB.

Is there any additional information you would like to share with us?

If possible, please upload any additional documents or information to support your medication request, such as repeat prescriptions or letters.

Upload any documents you think may be useful to us.

Max. file size: 4 GB.

2. About You

Name(Required)

Prefix First Last

What is Your Height & Weight(Required)

Please choose either Imperial or Metric

Imperial (Feet/Inch & Stone/Pound)

Metric (cm & Kg)

Height (Imperial)(Required)

Feet

.(Required)

Inches

Weight (Imperial)(Required)

Stone/Pounds

This field is hidden when viewing the form

Height Squared

Your BMI

Height (Metric)(Required)

Centimetres (cm)

Weight (Metric)(Required)

Kilogram (Kg)

This field is hidden when viewing the form

Height Squared

Your BMI(Required)

Address(Required)

Street Address Address Line 2 City County Post Code

Gender at Birth(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Phone(Required)

Email(Required)

3. Consent

Would you like us to notify your GP about this consultation and any treatments prescribed for you?(Required)

Yes

No

Consent(Required)

You are over 18 years old.

The treatment is intended solely for your use.

You will read the patient information leaflet provided with the medication.

You have answered all the questions truthfully and accurately, enabling our doctors to offer you a safe service, as inaccurate information can be hazardous to your health.

You agree to our terms and conditions, privacy policy, and acceptable use policy.

I agree to the privacy policy.

We’re Here Whenever You Need Us

View All Treatments

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NHS Prescriptions

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Email

customerservice@buryhealthcareonline.co.uk

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Contact Us

46 Walmersley Road,

Bury, BL9 6DP

0161 2221024

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