Rosacea

28/03/2023 04/04/2024

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 [email protected]

1. Hi. What is your name?

2. Are you purchasing this medication for yourself?

This consultation must be filled in by the patient using the medicine.

Yes No

3. Are you over 18?

The Family Chemist does not provide treatment to patients under 18.

Yes No

4. Are you breast feeding or pregnant or planning to become pregnant

Yes No

5. Do you smoke?

Yes No

5b. Would you like information on stopping smoking?

Yes No

6. Do you drink alcohol?

Yes No

6b. Would you like information on safe alcohol use?

Yes No

7. Are you overweight?

Yes No

7b. Would you like information on weight management?

Yes No

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

Please provide detailed areas of the parts of your body like nose, forehead etc.

9. Have you been diagnosed of Rosacea before by a doctor?

Yes No

9b. How long have you suffered with Rosacea?

<1yr

2-5yrs

5>yrs

10. Does the condition get better after treatment?

Yes No

10b. Please provide more details about why you think you suffer from Rosacea:

12. Is this flare up of Rosacea different to what you have experienced before?

Yes No

12b. Please provide more information

13. Have you used any other Rosacea treatments to treat your skin condition?

Yes No

13b. Please provide more information about what was used and its treatment response

15. We strongly recommend that you upload a picture of the location of your skin condition to help our prescribers make an informed prescribing decision safely. Especially if:

You are under 30
Have not been diagnosed with Rosacea before
Have not tried any Rosacea treatment before
Suffer from other skin conditions

Upload Image

16. Do you have any kidney or liver impairment?

Yes No

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

Yes No

17b. Please provide more details:

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

Yes No

18b. Please provide more details:

19. Are you allergic to any medicines or other substances e.g. peanuts or soya?

Yes No

19b. Please provide more details:

20. Would you like us to pass on details of your treatment to your GP?

Yes No

21. Do you agree with the following?

We cannot supply you with this treatment at this moment. Please contact our patient support team at [email protected] so we can talk through your options.

You will NOT use any of the treatments if you experience skin irritation (dryness, discomfort, erythema, peeling and blistering)
You will see your GP if your condition worsens or does not respond to treatment after 12w.
You do not apply Rosacea treatment on broken or sunburnt skin.
You should only apply Rosacea treatment on areas of Rosacea and avoid strong sunlight or UV light.
You have read the information available on the treatments and medication web page and understand the side effects, their effectiveness and alternatives available.
I will contact my GP if I experience no relief after 14 days or your symptoms persist after 28 days of treatment.
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 prescribing decisions will be based on the answers from your consultation 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

22. 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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