Psoriasis

Are you suffering an outbreak of psoriasis presently?

Yes

No

Have you ever applied Enstilar to your scalp?
If you have, when was this and how successful was it? If not, have you previously used any other psoriasis treatments? Were they successful?

Yes

No

Are you on any of the following medication?
Antibiotics. Antihistamines such as stemizole or terfenadine. Cisapride for stomach discomfort. Quinidine for circulatory problems. Pimozide for schizophrenia.

Yes

No

Did you know that we are unable to deliver Enstilar for use on the following parts?

Yes

No

Are you aware that Enstilarshould not be used to treat any of the skin problems listed below:
Psoriasis erythrodermic and pustular Perioral dermatitis (infected skin lesions) Ulcers or open wounds Acne or rosacea, which is it?

Yes

No

Did you know that?
If your condition does not improve after four weeks, you should consult a doctor. You must not use Enstilar on broken skin or beneath a bandage. You cannot use Enstilar aound the eyes or on the eyelids.

Yes

No

What's your gender?

Male

Female

Transmale (Born a female)

Transfemale (Born a male)

If female or transmale, are you currently pregnant, breastfeeding or planning to do so?
Please select your option

Presently Pregnant

Presently Breastfeeding

Planning on getting pregnant

Neither Pregnant nor Breastfeeding

Are you currently receiving any treatment or under any medication?
Please provide more information of the medication being used if any.

Yes

No

Does any of these describe you?
You have an underlying medical condition You've been through a major surgical procedure You have allergic reactions You have cardiovascular conditions or might have had suffered a stroke You suffer from a low liver or kidney function

Yes

No

Can you relate to any of the following conditions?
Difficulties with Calcium metabolism Calcium levels in the blood are high. Conditions or impairments of the liver or kidneys Disorders of calcium metabolism Hyperthyroidism Sarcoidosis and TB are two lung disorders. Cancer

Yes

No

Can you relate to any of the following?
You have an underlying medical condition You've been through a major surgical procedure You have allergic reactions You have cardiovascular conditions or might have had suffered a stroke You suffer from a low liver or kidney function

Yes

No

Did you know that new rashes, worsening rashes, and rashes that don't respond to treatment require further medical attention?

Yes

No

Do you have a fever or a general feeling of unease or illness right now?

Yes

No

Has a certified doctor or qualified medical practitioner examined you with psoriasis?
If not, please explain how you discovered you have psoriasis.

Yes

No

For which duration have you been experiencing psoriasis?

Have you noticed your psoriasis symptoms improving during the summer?

Yes

No

Have your symptoms changed since the last time you saw your doctor?

Yes

No

Kindly explain to us which specific parts of your body require this treatment
Kindly explain the affected area, where exactly on the body it is located and how it looks.

Please include a photo of your psoriasis in your submission.
This step is not mandatory however, it is important for you to answer especially if: Are over 30 years old Haven't tried any other therapy Have not seeked medical assistance about the condition. A photo will aid our medical team in making the best treatment option possible.

Only .jpg, .jpeg, .png, and .gif formats are allowed.(10MB file size limit)

Do you have a history of using coal tar to treat psoriasis?
It could be Polytar, Exorex, Sebco, or Psoriderm

Yes

No

Do you have a history of using oils or other creams to treat psoriasis?
If so, what did you use and how successful was it?

Yes

No

Can we share this information with your General practitioner?
Providing us with your physician's address means that you allow us to share this information with him/her for updated medical records if need be. It also allows our clinician to access your medical records if there is a need for that. We advice you share this treatment with your doctor for him/her to update your medical records.

Yes

No

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