Questionnaire about Dermatitis


Online Email Consultation: In order for Dr. Li to have a clear picture of your situation, please fill out the short questionnaire below. If possible, attach photo(s) of the affected area at the bottom of this form. After you have submitted the form, you will receive a confirmation that your form was processed. The form will be sent directly to Dr. Li for her review. Please allow 1-2 business days for a response. **

Your name:

Patient Name (if different)

 

Your Email Address:

 

Verify Email Address:

Cell Phone Number (Optional):

Sex:

Female Male

Age:

Race:

Weight:

(pounds)

How many years have you had Dermatitis?

Less than 1 year      1 to 5 years     6 to 10 years     11 to 20 years     over 20 years

Which part of your body does the dermatitis affect?

Face  Scalp  Arm  Leg  Hand  Foot  Body

What type of Dermatitis do you have?

Atopic   Contact  Seborrheic

Do you have any food allergy?

Dairy Products  Seafood  Gluten  Soy  Nuts  citrus Fruit  Other

What symptom of Dermatitis do you experience?

Red Rashes    Dry Patches    Oozing and blistering    

How Serious do you think your Dermatitis is?

Mild  Moderate  Severe

 Do you have any family member who has Dermatitis?

Yes  No 

Have you tried any alternative treatment?

Yes,  what kind?
No

How did you hear about us?


Please Specify: (such as Google, WebMD, etc..)

Please add any comments and questions you have below:

You may attach (optional) Pictures to help Dr. Li understand the situation:

Image1:

Image2:

Any personal information you submit to us is strictly confidential. Please take a look at our privacy policy to learn more


**Even though we have herbal Doctors ready to answer your questions, we can not provide medical advise on-line. Your medical doctor who knows your clinical history is the only person qualified to give you medical advise. We can only guide your use of our product and let you know how our product may be able to benefit your personal case.