ON LINE MEDICAL CONSULTATION

Clinic file
Name:
Age:
Gender:
Occupation:
Address:
City:
State:
Country:
Phone:
Email:

How long have you ever been suffering Psoriasis?

Please let us know the type of Psoriasis determined by your Dermatologist.

Specific symptoms & signs you have.

Silvery white scales

Itching

Vesicle

Pustule
Papula Eritomatosa
Scab varnish style
Hypocromic spot

Detached fine scales

General malaise

Fever

Location:  

Face & neck

Scalp
Hands
Body trunk
Axilla, groin & genitals
Legs & feet

General question & comments
How many treatments did you try?

Did you get better?

The symptoms, signs & lesions disappeared at all?

How long this improvement lasted?

How often are you exposed to the sun rays?

Please mention the kind of cloths do you prefer, long or short sleeve, texture, others.

A low resolution picture of your lesions could be necessary (optional)
Your additional comments:

Please be sure you answer all the questions required and then click send