Do you have any chronic conditions?

e.g., diabetes, hypertension, asthma

Are you currently taking any medications?

Have you had any surgeries in the past year?

Do you smoke?

Do you consume alcohol?

If yes, how much a day/weekly?

Who diagnosed your eczema and dermatitis?

Please provide more detail here

How long have you had symptoms?

How often are your symptoms?

Do any triggers worsen it?

e.g., activity, lying down, certain foods

Have you tried any treatments or self-care already?

Do you have any red flag symptoms?

e.g., activity, lying down, certain foods

Have you been prescribed treatment for this before?

Understanding of Risks

I have been informed about the potential side effects and interactions of the prescribed medication for Eczema and Dermatitis.

Medical Guidance

I agree to consult with my healthcare provider before starting any new medication.

I understand that the information provided in this assessment will be reviewed by a licensed pharmacist before my order is processed.

Consent to Share Information

I consent to my personal and medical information being used to assess my suitability for the prescribed medication.

I understand that my information will be kept confidential and used solely for the purpose of this assessment.

Confirmation

I confirm that the information provided in this assessment is accurate and complete to the best of my knowledge.

I understand that providing false information may result in my order being cancelled and may have health implications.