Questionnaire about Melasma


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)

Occupation:

How many years have you had Melasma?

Less than 1 year      1 to 5 years     over 5 years

Which area(s) are affected with Melasma?

Cheeks  Nose  Chin  Forehead

If female, have you given birth?

Yes,  How many?        
            What are the child ages?
No

Are you on the birth control pills?

Yes   No

Do you have outdoor activities very often?

Yes   If Yes, what kind?
No

WHat kind of Sunscreen do you use?

None  SPF 10-15  SPF 20-25  SPF 30-45  SPF 50+

What is your Skin Type? 

Oily   Normal   Dry   Sensitive   Combination

Are you on any medication or supplement?

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.