Eczema Assessment

07/01/2026 09/01/2026

To ensure you are provided with the most effective treatment by our healthcare professional please answer the questions honestly and accurately. The questionnaire should only take approximately 3 minutes to complete.

If you are unsure about any of the questions, please call us on 0115 8501944 or email us at enquiries@thefamilychemist.co.uk

About You

1. Hi. What is your name?

2. Are you purchasing this medications for yourself?

Yes No

3. Are you over 18 years?

Yes No

4. Are you breastfeeding or pregnant or planning to become pregnant?

We would not recommend steroid treatment through our service if pregnant, breastfeeding or planning to become pregnant, or start breastfeeding whilst on using the treatment. Please contact your GP or dermatologist.

Yes No

4b. Please provide more details.

Medical History

5. Which part of the body would you like to treat?

5b. Please confirm whether it is mild, moderate or severe eczema (if known):

6. Please provide a picture of the affected area(s) for assessment:

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7. Have you been diagnosed with eczema by a GP or dermatologist?

We are unable to provide steroid treatment for eczema through our service without a prior diagnosis of eczema. Please contact your GP or health provider for further assessment.

Yes No

7b. How long have you suffered with eczema?

First time

<1yr

2-5yrs

>5 years

8. Does this episode of eczema flare up differ in any way to your previous flare ups or is it getting worse/more difficult to manage?

Yes No

9. Are you currently using, or have you previously used any steroid creams or ointments (e.g. hydrocortisone, mometasone, betamethasone, clobetasone)?

Yes No

9b. Please provide more information on which steroid you have used and for how long:

10. Do you have, or have you ever been diagnosed with any of the following conditions:

Diabetes
Immune deficiency
Skin infection (fungal, bacterial or viral) in the affected areas

Yes No

10b. Please provide more information:

Past Medical History

12. Do you have any other medical conditions (e.g. cancer) or past surgical procedures (e.g. splenectomy)?

Yes No

12b. Please provide more details:

13. Are you currently taking or recently stopped taking any prescription medicines, over-the-counter medicines, herbal medicines or recreational drugs?

Yes No

13b. Please provide more details:

14. Are you allergic to any medicines (particularly steroids) or other substances e.g. peanuts or soya?

Yes No

14b. Please provide more details:

15. Would you like us to contact your GP?

Yes No

15b. Select your GP

Please Provide GP Email (preferred):

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16. Do you agree with the following?

You will NOT use any of the treatments on your face, neck, groin or genitals.
You will see your GP if your condition worsens, or does not respond to treatment in 7 days.
You understand that topical steroids are not first-line treatment and that you should regularly moisturise your skin during and after flare ups and understand that at least 30minutes should elapse before applying different topical preparations to the affected area (e.g. between steroid cream and emollient).
You understand that steroids should be applied thinly and to the affected areas only.
You understand that creams and ointments contain paraffin and can be flammable.
You have read the information available on the treatments and medication web page and understand the side effects, their effectiveness and alternatives available.
You will contact your GP if you experience no relief after 14 days or your symptoms persist after 28 days of treatment and that you will not continue to use steroids beyond 28 days as this can lead to thinning of the skin and permanent skin damage.
You have answered the questions honestly and accurately and the treatment is solely for your personal use.
You will read and understand the patient information leaflet supplied with your medication.
You understand that although it is not compulsory, it is important to inform your GP of this treatment so they can provide safe healthcare.
You understand that prescribing decisions will be based on the answers to your consultations, and incorrect information can cause harm to your health. Orders may be rejected if not clinically suitable.
You are aware The Family Chemist will undertake a soft check to validate your identity using LexisNexis. Note: This does not affect your credit rating.
You have read and agree to our Terms and Conditions, Terms of Use and Privacy Policy.

Yes No

16b. We cannot supply you with this treatment at the moment. Please contact our patient support team at enqiuries@thefamilychemist.co.uk so we can talk through your options.

Yes No

17. I confirm that I have read the information in this questionnaire and will follow the advice from the patient information leaflet before using the provided treatments.

Yes

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Eczema Assessment

About You

Medical History

Past Medical History

0115 850 1944

enquiries@thefamilychemist.co.uk

Unit 1, Wilford Business Park,
Ruddington Lane,
Nottingham,
NG11 7EP

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About You

Medical History

Past Medical History

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