Eczema prescription questionnaire

Name *

First

Last

Date of Birth *

Email *

Address *

Select Pharmacy to where prescriptions should be sent. Select "other" if you can't find your pharmacy *

1. Please share your birth gender *

Male
Female
Other

Are you currently trying to get pregnant, are pregnant or breastfeeding? *

Please share more information with us *

2. Have you received a eczema diagnosis from a doctor or skin specialist ? *

3. Please share with us the current symptoms you have(Select all that apply) *

Cracked skin
Red or inflamed patches of skin
Blisters
Dry skin
Itchy skin
Crusting/ Weeping of the skin
Other

Please share more information with us *

4. Please share the part of your body where you are experiencing symptoms(Select all that apply) *

Skin creases (elbow or back of knees)
Groin or genitals
Face
Arms/legs
Torso/Chest
Scalp
Armpits
Hands and feet
Other

Please share more information with us *

5. Please confirm if any of the following apply to you and your eczema episodes *

It gets worse during different seasons of the year (e.g. you experience flare-ups in the winter)
It is triggered by irritants such as jewellery, soaps, certain make-up, metals
It is triggered or worsens with lifestyle impacts such as diet, alcohol or stress
It may be impacted by medication I use or another illness I have
None of the above/I am unsure

6. Aside from your current skin symptoms, are you currently feeling any of the below *

Feeling generally unwell
Fever with a high temperature
Runny nose
Asthma
None of the above

7. Please share the current treatments you are currently using for your skin condition? *

Steroid ointments or creams and would like to continue using this
Steroid ointments or creams but I would like to try an alternative
Runny nose
Moisturisers
I am not using anything right now
Other

Please share more information with us *

Please confirm why you are unhappy with the treatment you have used previously? *

8. What treatments have you used previously for your skin condition? *

Eumovate
Betnovate
Diprosone
Elocon
Hydrocortisone
Other

Please share more information with us *

9. Aside from what you have already mentioned, please share if you have had any other significant illnesses, conditions or any past surgeries/hospital stays? *

Please share more information with us *

10. Please share if you are currently taking any prescription or over-the-counter medications, or are currently using recreational drugs? *

Please share more information with us *

11. Do you currently have any allergies? *

Please share more information with us *

12. Please confirm the following statement: The best treatment for a skin condition such as eczema is with a short-term use of steroid creams and long-term use of moisturizers. *

Correct

13. Is there anything else you would like to share before we finish? *

Please share more information with us *

14. It is advised that we tell your GP about any treatment we provide to you. Would you like Dronline to share any information regarding this treatment with your GP? *

Please provide your GP details with us (Name, address, email/phone) *

15. I can confirm that I have answered all the questions honestly and to the best of my knowledge. This treatment is just for my own self use. There are side effects with treatments, and I understand these. If I would like to know about alternative treatment options, I can book a video appointment and discuss with a Dronline GP. *

I confirm, and I understand

Upload two photos of the affected area *

Click or drag files to this area to upload. You can upload up to 2 files.

Price

Total Amount: 25 €

Pay with a Debit or Credit Card *

Card

Name on Card

Get a Prescription for Eczema