Myonlinedoctor Erectile dysfunction treatment Registration Page

In order to prescribe treatments for Acne our doctor needs some information regarding this specific condition. Please complete the following as accurately as possible.

How long have you been suffering from acne?

Which areas of your skin are affected?

Chin
Nose
Forehead
Cheeks
Neck
Back
Chest
Other

How does the acne manifest itself?

Whiteheads
Blackheads
Nodules (lumps tender to the touch under the skin)

Does your skin scar when healing?

Yes No

What is your skin type/tone?

Do you suffer from any other skin condition such as eczema, psoriasis, rosacea, couperose, dermatitis or cutaneous epithelioma?

Yes No

Are you currently taking or have you previously taken any prescription drugs against acne?

Yes No

How else are you treating your acne?

Is there a particular treatment you are interested in receiving for your acne?

Yes No

Are you pregnant or trying to conceive?

Yes No

Are you breastfeeding?

Yes No

Do you suffer from irregular periods and/or excess facial and body hair growth?

Yes No

Are you using any form of hormonal contraception?

Yes No

I confirm that the submitted photographs are recent images of my own skin

I understand that in cases of severe acne it is best to seek treatment from a specialist dermatologist

Patients taking oral treatments for acne may be at risk of liver damage. I understand and confirm that when taking oral acne treatments continually I should take a liver function test every 6 months

Do you smoke?

Yes No

Questions Related to Acne