Medical & Background Information Questionnaire

First Name *

Last Name *

Date of Birth *

Phone Number *

Main reason for your appointment? *

Concern regarding specific skin spotRoutine full skin checkAcneRosaceaEczema/psoriasisOther rashCosmetic consult/procedureOther (please describe in your words)

Comments

Please be aware, if you have more than one problem further consultations may be required to deal with these. If relevant please provide further information of the above.

When did your problem start? *

What treatment (tablets/creams) have you tried so far? (including prescription, pharmacy or nephropathy) *

Do you have any family history of similar problems? *

YesNo

How much are you affected by your skin condition? *

SeverelyModeratelySlightly Not at all

Do you know what caused it or what makes it worse? *

Please list your other regular medications

Do you have any allergies to medications? *

Do you have a history of skin cancers being removed? *

BCCSCCMelanomaNo Unsure

What is your usual occupation? *

Please tick if you have ever had one or multiple of the following?

HAYFEVERCHRONIC FATIGUEHEART PROBLEMSASTHMALUPUS/AUTOIMMUNE DISEASEBLOOD PRESSUREDIABETESSTRESS RELATEDHEALTH PROBLEMSLUNG PROBLEMSDEPRESSIONCANCER (other than skin)LIVER PROBLEMSANXIETYKIDNEY PROBLEMSCHOLESTEROL

Please provide any further relevant information

Please wait, files are uploading..

Thank you for completing this form.

Complete Skin Specialists Team

Ph: 03 9740 2409 Fax: 03 9740 2889

info@completeskinspecialists.com.au