Dermal Diagnosis - 2025 [Sept]

# demographics
Demographics

MY PERSONAL DETAILS

We require this information to track your progress and provide you with the best advice and insight.
My First Name*
My Last Name*

Demographics

MY PERSONAL DETAILS
My Date Of Birth*

DayMonthYear
Date
Birthdate
My Age
To ensure your results are accurate, please make sure the age value is correct*

I confirm my age is correct
Age Verification

Thank you for entering your birth date. It appears that you are under the age of 18. As a minor, registration must be completed by an adult (parent or legal guardian).

Please confirm in the checkbox below that you are an adult filling out this form on behalf of a minor.
I confirm that I'm an adult filling out this form on behalf of a child or teenager.
Age Verification

Thank you for entering your birth date. Based on the information provided, the age appears to be under 7. Unfortunately, our Dermal Diagnosis form are not designed for children age 7 and below.

Please verify the information if the date was entered incorrectly. Alternatively, please get in touch with our support team for services tailored to younger children.

Medical Background

My Hormone Therapy History
My history of gender-affirming treatment in the form of Hormone Replacement Therapy (HRT)

I'm currently on hormone therapyI underwent hormone therapyI'm not and have never been on hormone therapy
My history of Hormone Replacement Therapy (HRT)

I'm currently on hormone therapyI underwent hormone therapyI'm not, and have never been on hormone therapy

Medical Background

My Steroid Use History
Please answer the below question for prescription as well as non-prescription steroids:
My steroid use history is:*

noneI have used steroids in the pastI'm currently on steroid treatment
The last time I received steroid treatment was*

in the last 6 months6 to 12 months agomore than a year ago

Medical Background

My Allergenic History

* Select all that apply and click next
I develop allergies when I... *

I don't have any known allergieseat certain foodstake certain medicationsam exposed to certain environmental factors e.g. cat hair or dustam in contact with certain substances e.g soap or washing powderam in contact with certain elements e.g gold or nickel
allergen selected

yes
Error! You indicated that you don't have any allergies, but also selected an allergen. Please rectify the error to proceed.

Inflammatory Conditions

My Skin's Dermatitis Risks
The itching I experience on my face or scalp*

only occurs when triggered by allergensoccurs even when I attempt to avoid all allergensI don't experience any itching on my face or scalp
I notice scaly, rough patches on my skin or scalp that are sometimes itchy or flaky*

yesno
The above symptoms on my face or scalp are*

small and infrequentoften present and cover a moderate areaextensive and almost always present

Inflammatory Conditions

My Skin's Dermatitis Risks
The best description for the scaly patches / flakes / broken skin areas on my skin is:

Please select the image closest to the symptoms you experience - even if it's only a tiny area.
Dry Skin Patches: Areas with dry skin with white or ashy flakes. Mild or no itchiness and redness.

Dry, Itchy Skin Scales:Extremely itchy, dry scales with thickened skin.

Oily, Itchy Skin Scales: Red skin with oily, itchy skin scales. The scales may be yellow or white.

Inflammatory Conditions

My Skin's Acne Risks
I have the following type/s of breakouts:

Important: Read the description of each breakout type to ensure your selection is accurate. Select all the images that apply to you.
- Blackheads: Small, dark spots
- Whiteheads: Small, flesh-colored or slightly red bumps, and not painful
- Papules: Red, slightly raised bumps, and sometimes tender
- Pastules: Larger, clearly visible bumps, filled with pus, and may be painful
- Nodules / Cysts: Large, pus-filled, painful lumps, deep under the skin
I typically have the following amount of comedones (blackheads/whiteheads) at any one time*

Few (less than 50)Several (50-100)Many (more than 100)

Inflammatory Conditions

My Skin's Acne Risks
I have breakouts or congested pores in the following area/s:

Please select the images of all the applicable areas.