Eczema - WePrescribe

Eczema / Dermatitis Consultation

Are you a female?

What is your D.O.B (dd/mm/yyyy)

Has a healthcare professional ever diagnosed you with eczema?

Please select if you feel any of the following apply to your eczema?

Caused by any medication you may be taking

Triggered by any perfumed or scented products, jewellery, makeup or any other products

None of the above or I’m not sure

Affected by the weather

Triggered by anything in your diet or stress

Are you currently experiencing any of the following alongside your current symptoms?

- Fever or bad shaking
- Feeling unwell
- Asthma symptoms or shortness of breathe
- Runny, watery discharge from the nose

Are you currently or have you previously used any topical medicines for your eczema?

Please provide more details

Have you ever previously been diagnosed with any other medical conditions?

This includes conditions such as - Asthma - Kidney disease - Liver disease - Eczema

Please provide more details

Do you suffer with any allergies?

Please provide more details

Do you currently take any medication? This includes herbal remedies and over the counter medication.

Please provide more details

Are you pregnant, planning a pregnancy or breast-feeding at the moment?

Is there any other information you would like to share with our prescribing team?

If so, please provide more information

Please provide more details

We strongly recommend that you inform your GP of any treatment you receive. Would you like WePrescribe to do this on your behalf?

I have read and understood the Terms and Conditions.

Please see our terms and conditions here

Eczema Consultation