Your New GetSkinHelp Request
Name
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First Name
Last Name
Email
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Please enter your preferred email address.
Date of Birth
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Month
-
Day
Year
This is for verification purposes.
Date of Birth
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This is for verification purposes.
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What is the reason you are returning?
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I have a new skin condition.
My previous condition has come back or has worsened.
Other
What is your concern?
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Acne
Eczema (atopic dermatitis)
Lesion / skin cancer
Melasma
Psoriasis
Rosacea
Vitiligo
Other
Your Pharmacy Information
Would you like to update your pharmacy information?
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No, please use my pharmacy information on file.
Yes, please change my pharmacy information.
Please send my prescription to Main Drug Mart pharmacy and have them contact me regarding payment and delivery.
Pharmacy Name
*
Pharmacy Phone Number
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Please enter a valid phone number.
Pharmacy Fax Number
Please enter a valid phone number.
Images of Your Skin Concern
Please submit current mages of your skin concern for the medical team to review.
Submit 3-5 pictures of your skin concern.
Please make sure all pictures:
are in focus.
contain a point of reference, like a coin or a ruler.
indicate where on your body it can be found.
*
Browse Files
Drag and drop files here
Choose a file
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of
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Acne Questionnaire
Please answer the following questions about your skin condition
How old were you when you first had acne?
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Please Select
In childhood
age 10-14
age 15-20
age 21-30
> age 30
recently
How would you describe your acne? (Please select all that apply.)
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Pimples
Blemishes
Redness
Blackheads
Scarring
Oily skin
What areas are affected? (Please select all that apply.)
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Face
Forehead
Nose
Chin
Jawline
Neck
Chest
Back
Shoulders
Groin
Buttocks
How severe do you consider your acne?
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Very mild
Mild
Moderate
Severe
Very severe
Does your acne affect your quality of life?
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Does not affect it at all
A little bit
Quite a bit
Extremely bothersome
How does your acne today compare to how it was a few months ago?
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Staying about the same
Slightly worse
Getting much worse
Getting better
Getting much better
I don't know
What are some triggers for your acne? (Please select all that apply.)
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Stress
Picking
Menstrual changes
I don't know
Other
Do you have any of the following symptoms? (Please select all that apply.)
Facial flushing
Depressed mood
Anxiety
Unusually heavy or irregular periods
Hair growth on the face of chest
What treatments have you tried so far? (Please select all that apply.)
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Washing face at least twice daily
Acne cleansing soap
Benzoyl peroxide cream
Oral antibiotic for acne
Topical antibiotic for acne
Birth control pill
Accutane
Other
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Eczema (Atopic Dermatitis) Questionnaire
Please answer the following questions about your skin condition
What symptoms are you experiencing? (Please select all that apply.)
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Itchiness
Dry or flaky skin
Thickened or cracked skin
Reddish-brown patches
Other
Where are these spot(s) are your body?
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How long has it been present for?
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Which of the following worsens your eczema? (Please select all that apply.)
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Stress
Winter / dry weather
Irritants and/or foods
Other
What were your previous treatments? (Please select all that apply.)
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Steroid creams
Moisturizers
Protopic/Eledel
Other
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Skin Lesion Questionnaire
Please help us understand more about your skin lesion
Do you have a history of skin cancer or dysplastic nevus?
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I have no personal history of skin cancer or dysplastic nevus.
I have been diagnosed with skin cancer or dysplastic nevus in the past.
I'm not sure.
Does your family have a history of skin cancer or dysplastic nevus?
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None of my family members have been diagnosed with skin cancer or dysplastic nevus.
One or more members of my family have been diagnosed with skin cancer or dysplastic nevus in the past.
I'm not sure.
Please specify the type of skin cancer (Please select all that apply.)
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Basal Cell Carcinoma (BCC)
Squamous Cell Carcinoma (SCC)
Melanoma
Other
Have you experienced any of the following symptoms? (Please select all that apply.)
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Sudden change in colour
Sudden change in shape of the lesions
Continually bleeds or oozes
Crusts over but refuses to heal
Sudden change in size
Has not changed over time
Have you had a biopsy of the lesions?
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Yes
No
What did the biopsy show?
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Skin cancer risk assessment. (Please select all that apply.)
I am frequently in the sun because of my job, hobbies, etc.
I have a history of using tanning beds
I am immunosuppressed or immunocompromised
I use photosensitive drugs
None of the above
Do you take any of the following photosensitive drugs? (Please select all that apply.)
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Tetracycline
Doxycycline
Flouroquinolones
Sulfonamides
NSAIDS (i.e. ibuprofen)
Retinoids
Phenothiazines
Other
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Melasma Questionnaire
Please answer the following questions about your skin condition
Where do you have your brown spots? (Please select all that apply.)
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Forehead
Bridge of nose
Cheeks
Upper lip
Forearms
Neck
Shoulders
Other
How long have they been present for?
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Did your melasma appear during or after any of the following situations? (Please select all that apply.)
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During pregnancy
After starting oral contraception
After hormone treatments
After sun exposure
After trying a new skin product
What treatments have you tried so far?
*
Do you use sunscreen on a daily basis?
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Yes
No
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Psoriasis Questionnaire
Please answer the following questions about your skin condition
How long has your rash been present for?
*
Where is your rash? (Please select all that apply.)
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Arms
Elbows
Legs
Scalp
Face
Torso
Other
What symptoms are you are experiencing? (Please select all that apply.)
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Itchiness
Dry or cracked skin
Thin or pitted nails
Swollen or stiff joints
Red patches on the skin
Other
Do you have any of these additional symptoms? (Please select all that apply.)
Arthritis - pain or swelling in joints
Ocular symptoms - blurred vision, pain, redness in eyes, and sensitivity to light
What triggers the above symptoms? (Please select all that apply.)
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Stress
Cold or dry weather
Recent colds or infections
Other
What treatments have you tried so far? (Please select all that apply.)
Check if used before
Name of medications
Topical
Phototherapy
Systemic drugs
Biologics
Do you have any of the following medical problems? (Please select all that apply.)
Diabetes
Hypertension
High cholesterol or dyslipidemia
Body mass index (BMI) greater than 30
Inflammatory bowel disease (IBD)
Depression
None of the above
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Rosacea Questionnaire
Please answer the following questions about your skin condition
What symptoms are you experiencing? (Please select all that apply.)
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Pus filled bumps
Facial flushing
Baseline redness
Dry, irritated or swollen eyes
Enlarged nose
Enlarged chin
How long has this been present for?
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What triggers the above symptoms? (Please select all that apply.)
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Hot drinks and spicy foods
Red wine and other alcoholic beverages
Temperature extremes
Sunlight or wind
Dry or cold weather
Exercise
Drugs that dilate blood vessels (i.e. blood pressure medications)
Various cosmetic products or sunscreen
Other
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Vitiligo Questionnaire
Please answer the following questions about your skin condition
How long has this been present for?
*
Where are these depigmented spots located? (Please select all that apply.)
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Face
Fingers
Elbows
Knees
Genitals
Feet
Whitening of hair
Whitening of eyebrows
Whitening of beard hair
Other
What treatments have you tried so far? (Please select all that apply.)
Check if used before
Name and duration
Topical creams
Light Therapy
Laser
Surgical
Are your depigmented patches triggered by any of the following? (Please select all that apply.)
Stress
Recent illness
Herpes simplex virus
Other
Is there any history of the following in your family? (Please select all that apply.)
Vitiligo
Diabetes type I
Lupus
Thyroid disease
Vitamin B12 deficiency
Autoimmune amyloidosis
Other autoimmune diseases
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Medical Questionnaire
Please answer the following questions about your skin condition
Describe the symptoms you have been experiencing:
*
How long has this issue been present for?
*
What creams or medications have you used for this condition?
*
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Your Medications & Allergies
Are there changes to your medications?
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Yes
No
Please list any medications you are taking and the dosage
Medication Name
Dosage
1.
2.
3.
4.
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Your Appointment Details
Please select ALL the times you are available. (We will do our best to accommodate your preferences.)
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MON
TUE
WED
THU
FRI
Morning
Evening
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