Questionnaire about Rosacea


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 rosacea?

Less than 1 year      1 to 5 years     over 5 years

What symptom of Rosacea do you experience?

Facial Flushing    Pimples on the face    Swollen Bumps on the nose     Broken Capillary     Eye Irritation

Where do your Rosacea symptom appear?

Cheeks  Nose  Chin  Forehead

Do you have any physical sensation of your Rosacea?

None  Pain  Itchy   Other

How Serious do you think your Rosacea is?

Mild  Moderate  Severe

What is your Skin Type? 

Oily   Normal   Dry   Sensitive   Combination

What type of treatment have you used before?

Topical  Oral Other

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.