Medical Questionnaire

Disclaimer

Please be advised, in order for the Dermatology Specialist to provide feedback, you will be required to submit a minimum of TWO clear photographs of the affected area for review.

General Information

Patient first name *

Patient surname *

Date of birth *

Are you already receiving treatment from RPM Derma? *

YesNo

Name of current treatment *

Duration of use of treatment (if known)

Any problems/concerns/irritations? *

YesNo

If yes, please provide further details *

Any changes to general health? *

YesNo

If yes, please provide further details *

Any changes to sexual health? *

YesNo

If yes, please provide further details *

Any new medications/supplements? *

YesNo

If yes, please provide further details *

Any problems with application? *

YesNo

If yes, please provide further details *

Any changes to mood? *

YesNo

If yes, please provide further details *

Any chance you could be pregnant? *

YesNo

*If there is a chance you could be pregnant, please contact the clinician at the earliest convenience*

Please upload clear, sharp and recent photos of concerned areas. *

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Treatment Continuation

Do you wish to continue with the same treatment or do you wish to request modifications? *

Continue with same treatmentRequest change/modifications

If you wish to request a change/modification to your treatment, please contact the clinician directly or book a consultation

Further Information

Email Address *

Mobile / Phone number *

Gender at Birth *

MaleFemale

We request for patients to confirm their gender assigned at birth as sex hormones can significantly influence treatment outcomes.

Photo ID *

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We require photographic identification to verify that the prescription is issued exclusively to the intended individual. This is in accordance with CQC regulatory requirements and ensures that all patient safety protocols are fully upheld.

Address *

Street address *Street address line 2

City *

State

Postcode *

Country

Occupation

Do you consume alcohol? *

NeverDailyOnce a weekOnce a monthOnce a year

Do you smoke? *

YesNoI used to smoke

Do you use recreational drugs? *

NoI have previously usedI currently use

Health Information

Do you have any medical conditions, you are treated or known for ? i.e, asthma, eczema, hypertension , other *

YesNo

Please list all your medical conditions *

Check the one which applies to you *

Pregnant Breastfeeding Planning to become pregnant in near future Not pregnant or breastfeeding

Any means of contraception? Please list i.e pill, coil, implant

Check the conditions that apply to any member of your immediate relatives: *

Cardiac DiseaseThyroid Disease CancerKidney diseaseLiver disease Pancreatic diseaseNot known or no history of any medical conditionsOther

Please list any condition which are significant and not mentioned *

Are you taking any prescribed medications? *

YesNo

Please list your current prescribed medications, including dose *

Are you taking any supplements, herbal treatment, alternative treatment? *

YesNo

Please any supplements, herbal treatment, alternative treatment you are currently taking *

Do you have any medication allergies? *

YesNo

Please list any medication allergies *

Do you have any other allergies and known intolerances ? i.e . pollen, plaster, food *

YesNo

Please list all your other allergies and known intolerances *

Your Concern

WHAT IS YOUR CONCERN TODAY ? *

Hair and Beard Area ( hair loss, reduced density etc.)Skin Condition ( acne, rosacea, melasma, pigmentation etc)

Tick all the areas of HAIR LOSS AND BEARD CONCERNS *

Frontal Crown ( top of the head)Occipital ( back of the head)BeardEyebrowsEyelashes Other

Please provide more information

Check the symptoms that you're currently experiencing: *

Hair LossHair thinningScalp irritationScalp flakinessScalp itchBald patches Other

Provide more information

What is your main skin concern? *

AcneRosaceaMelasma/HyperpigmentationEczemaSeborrheic eczemaOther

Please describe

Check the symptoms that you're currently experiencing: *

Dry skinOily skinRednessItchinessLarge poresSpots or AcneScarringWrinklesPuffinessHyperpigmentation ( darkening of skin )Hypopigmentation ( lightening of skin) Other

Please provide more info

When did you first notice your symptoms? *

Has anyone in your family had the same symptoms or currently having? *

History of treatment up to today. Please list all prescribed and over the counter treatment *

Please upload clear and sharp photos of concerned areas. 2 minimum *

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Treatment

Please specify the name of the treatment you wish to purchase *

Do you require an active discussion with the Dermatology Specialist? *

YesNo

Please select *

WhatsApp or Phone CallVideo CallIn Person Consultation

If you require an active discussion with the Dermatology Specialist, please book via the links below

Please be advised, WhatsApp / Phone Call and Video Call consultations are a remote discussion.

WhatsApp or Phone Call | £30 (redeemable against purchased product)

Video Call | £160

In Person Consultation | £160

Our admin team may request additional information via email or phone. However, should an active discussion with a clinician is required via WhatsApp or phone call (approx. 5 mins), this will be charged at £30, redeemable against purchased product. Please be advised, in some cases, a higher-tier consultation may be required to ensure safe and effective treatment.

Additional Information

Is there anything further you feel the clinician should know?

Consent

By submitting this form, you are declaring that all the information provided is true and complete to the best of your knowledge. You confirm that you have not omitted any details that could affect your ability to receive treatment or safely use the product. You understand that providing inaccurate or incomplete information may impact the safety and effectiveness of your treatment. You consent to our team contacting you via the contact detials you have provided *

Your personal and medical information is collected and stored securely in accordance with the UK General Data Protection Regulation (GDPR) 2018 and the Data Protection Act 2018.This information is used solely for the purposes of providing safe and effective medical care, managing your treatment, and fulfilling legal or regulatory obligations.

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