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Physician Diagnosis Questionnaire

Questions

Pharmacy

Information

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Initial Questions:

Is this your first breakout?
Where on your body are you currently experiencing symptoms? Check all that apply.
When did the symptoms start?
What symptoms are you currently experiencing? Check all that apply.
Do you have a kidney or liver condition that prevents you from taking prescription medication?
Are you currently pregnant or could you be pregnant?
Do you have any major or relevant medical conditions that the physician should be aware of?
When was your last outbreak?
Approximately how many outbreaks have you had in your life time?
Are you taking any prescription medication?
Are you taking any prescription medication for herpes now?
Are you taking any over-the-counter medications for herpes now?
Have you previously taken any prescription medication for herpes?
Is there any additional information that you would like your physician to be aware of?
Please provide your email:

Pharmacy Search:

Nearby Pharmacies:

Search by Zipcode:

Personal Information:

*Provide DOB.

*

Please double check your # as you will need it to access your case.

UPLOAD PHOTOS OF THE AFFECTED AREA

Overview photo (12 inches away)


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Overview photo (Arm's length away from the affected area)


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Case Review



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Initial Questions:

First Breakout:
Symptoms Place:
When Did Symptoms Start:
Symptoms Type:
Last outbreak:
Taking Prescription Medication:
Taking OTC Medication:
Previously Taken Prescription Herpes Medication:
Taking Prescription Medication For Herpes:
Kidney Or Liver Condition:
Currently Pregnant Or Could You Be Pregnant:
Relevant Medical Conditions:
Outbreaks In Your Life Time:
Additional Information:


Prescription Info:

Name:
Email:
DOB:
Address:
City:
State:
Zip:
Phone Number:
Preferred Pharmacy:


Payment Method

Diagnosis Cost: $99.00


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