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Clinic Psoriasis

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Registration
First Name: * +
Middle Name: +
Last Name: * +
Username: i * +
E-mail: i * -
Password: i * -
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City: * +
State: * +
Country: * +
What is your Present Age?: * +
Please indicate your gender: Male Female * +
Kind of Psoriasis Condition:
Plaque Psoriasis (P)Inverse Psoriasis
Pustular Psoriasis (PP)Scalp Psoriasis
Palmo Planter (PPP)Psoriasis Arthritis (PA)
Pustular Palmo Planter (PPPP)Genital and Goen Psoriasis (GGP)
Gutate PsoriasisNail Psoriasis
Erythrodermic Psoriasis
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Your Age when Psoriasis First Appeared: i +
State (in number of years) Age of your Current Psoriasis Condition: i +
Severity Level of your Current Psoriasis Condition: i +
How Stable is your Current Psoriasis Condition: i +
How your Psoriasis condition behave after the end of every flare up period?:
Get Worst Remains Same Not Applicable
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WHAT CAUSED YOUR PSORIASIS TO START?:
I was Stressed
Skin injury developed my Psoriasis
I had a severe soar throat
It started as reaction from some medicines I took
Other Reasons
Unknown
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In General What causes a new flare up in your Psoriasis Condition?:
Whenever I am in deep stress or in depression.
Prolonged and Severe Soar Throat
Whenever I have a skin injury
Generally in cold weather
Whenever I stop my psoriasis medication
Some other reasons
Not applicable - No flare up in the Last 36 months
I do not know
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Select parts of your body which are covered with psoriasis at present?:
ScalpElbowsLegs
FaceStomatchGenital Parts
Lower and Upper ArmsBackNails
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Other Body areas not listed above: i +
In general what is the size or psoriasis liesons or patches on your body?: +
What is the thinkness of your liesons: +
What is the color of your Liesons: +
Does your Liesons Bleed?:
No Bleeding Occasionally Regular
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Is there any pus formation in your liesons?:
No Pus Regular Pus Formation Pus with Bleeding
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Tell us about Itching if present?:
No ItchingItching spell starts during day time onlyNo medication is effective on my Itching
Mild and Occassional ItchingItching spell starts at night only
Severe and Untolrable Itching spellsUsing cream or medicine stops itching for few hou
Itching spell stards any timeUsing cream or medicine stops itching for few days
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What is the condition of your Nails:
My Nails are clean and Flat
My Nails are pitted
My Nails are deformed and raised
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Tell us in detail about your nail condition: i +
At what age Psoriasis Arthritis (PA) developed: i +
At which Joint PA developed first?: +
Select all Joints effected by PA at present:
No I do not have Joint PainElbowSpine
Small Joint of HandAncleAny other joint not listed above
Small Joint of FeetCervical
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State whether you are Vegetarian or Non Vegetarian: Vegetarian Non Vegetarian +
Describe in detail food items you eat in every meal: i +
Tell us about your drinking habits: +
Tell us about your smoking habits: +
Check if you are taking any drugs: +
Tell us in detail about your constipation conditions: +
Do you feel burning sensation after taking meals?:
Yes No
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If taking any medication for constipation, heart burn or any other digestion problem? Please provide details.: +
Temperature and Climate conditions of your city: i +
What part of the year do you see aggression or flare up in your psoriasis condition:
Summer Time Winter Time No Change
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What is the nature of job you are doing?: +
What is the level of your job stress:
Very Stressfull Somewhat Stressfull No Stress
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Any other stress conditions?: i +
Are you taking any kind of stress medical? Please provide details: +
Do you do exercises/yoga?:
Regular Occassional Never
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Do you have psoriasis in your family? Please provide details.: i +
Treatment Regimen
Given below are the major group of Treatment Regimens.
To manage your psoriasis condition which of the following treatment regimens you are currently using or used in the past?
select all applicable. Answer for each group separately, including Effectiveness of each treatment regimen.
Group I - Moisture Creams such as Vaseline etc. Select all Applicable:
Never Used this treatmentIts use developed side effects
Used it for less than 2 yearsIts use developed flare ups
Used it for more than 2 yearsIt does not work any more
Currently using this treatmentIt never worked on me
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Group II - Herbal and Natural Products such as Slippery ELM, Herbal Teas, Coal Tar, Pagano Diet, and other similar products. Select all Applicable:
Never Used this treatmentIts use developed side effects
Used it for less than 2 yearsIts use developed flare ups
Used it for more than 2 yearsIt does not work any more
Currently using this treatmentIt never worked on me
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Group III - Homeopathy Treatment. Select all Applicable:
Never Used this treatmentIts use developed side effects
Used it for less than 2 yearsIts use developed flare ups
Used it for more than 2 yearsIt does not work any more
Currently using this treatmentIt never worked on me
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Group IV - Dead Sea Salt Treatment. Select all Applicable:
Never Used this treatmentIts use developed side effects
Used it for less than 2 yearsIts use developed flare ups
Used it for more than 2 yearsIt does not work any more
Currently using this treatmentIt never worked on me
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Group V - Other Soft OTC Products. Select all Applicable:
Never Used this treatmentIts use developed side effects
Used it for less than 2 yearsIts use developed flare ups
Used it for more than 2 yearsIt does not work any more
Currently using this treatmentIt never worked on me
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Group VI - Steroid based prescription drugs. Select all Applicable:
Never Used this treatmentIts use developed side effects
Used it for less than 2 yearsIts use developed flare ups
Used it for more than 2 yearsIt does not work any more
Currently using this treatmentIt never worked on me
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Group VII - Vitamin D based treatment such as Dovanex. Select all Applicable:
Never Used this treatmentIts use developed side effects
Used it for less than 2 yearsIts use developed flare ups
Used it for more than 2 yearsIt does not work any more
Currently using this treatmentIt never worked on me
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Group VIII - Steroid and Vitamin D combination products such as Taclonex. Select all Applicable:
Never Used this treatmentIts use developed side effects
Used it for less than 2 yearsIts use developed flare ups
Used it for more than 2 yearsIt does not work any more
Currently using this treatmentIt never worked on me
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Group IX - UV Radiation based therapies. Select all Applicable:
Never Used this treatmentIts use developed side effects
Used it for less than 2 yearsIts use developed flare ups
Used it for more than 2 yearsIt does not work any more
Currently using this treatmentIt never worked on me
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Group X - Methotrexate, Cyclosporin, Acitretin or other similar prodcuts. Select all Applicable:
Never Used this treatmentIts use developed side effects
Used it for less than 2 yearsIts use developed flare ups
Used it for more than 2 yearsIt does not work any more
Currently using this treatmentIt never worked on me
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_UE_MH_METHOTREXATE_NAME: i +
Group XI - Biologics based treatments such as Enbriel, Reptiva, Remicade etc. Select all Applicable:
Never Used this treatmentIts use developed side effects
Used it for less than 2 yearsIts use developed flare ups
Used it for more than 2 yearsIt does not work any more
Currently using this treatmentIt never worked on me
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_UE_MH_BIOLOGICS_NAME: i +
Any other detail you want to provide regarding different treatments you used in the past.: i +
Do you have problem of Falling Hair? If yes, Please provide detail here.: i +
Do you have problem of Dandruf? If yes, Please provide detail here.: i +
Do you have problem of Hypertension? If yes, Please provide detail here.: i +
Do you have problem of High Blood Pressure? If yes, Please provide detail here.: i +
Do you have problem of Depression? If yes, Please provide detail here.: i +
Do you have problem of Cardiac Heart Disease? If yes, Please provide detail here.: i +
Do you have problem of Asthma? If yes, Please provide detail here.: i +
Do you have problem of Thyroid? If yes, Please provide detail here.: i +
Do you have problem of Kidney? If yes, Please provide detail here.: i +
Do you have problem of Severe Indigestion? If yes, Please provide detail here.: i +
Do you have problem of Bowl Movement Syndrome? If yes, Please provide detail here.: i +
Do you have problem of Chronic Soar Throat? If yes, Please provide detail here.: i +
Do you have problem of Diabetes? If yes, Please provide detail here.: i +
Your Personal and Intimate Life Activities Section
Given below are a series of questions on your sexual life.
If you feel uncomfortable answering these questions then do not answer them here.
answer these questions directly to doctor through communication center.
We are asking these questions as your sexual life also plays a major contributory cause in your psoriasis problem.
How often do you perform sexual act? (on an average): +
Generally how much time gap you give between a meal and sexual act?: i +
Does stress full day effects your Sexual Performance? please select all applicable:
I do not feel having desire
I get focused on my part and enjoy
I feel dissatisfied afterwards
I feel relaxed afterwards
I feel more stressfull afterwards
None of above applicable
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Are you suffering from the problem of erectile dysfunction?:
Yes No
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In general do you feel satisfied after performing sexual act?:
Yes No
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In general do you feel your partner is satisfied after performing sexual act?:
Yes No
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Any other detail you want to provide about your sexual life.: i +
Space for Residual Remarks
Given below is the space for the residual remarks. please feel free
to use this space as much as possible and tell every thing which you want to tell your doctor.
Also if you feel that in some of the questions you wanted to say some thing more
or wanted to give some further clarification then please use this space to give
those answers by referring to that question.
Please provide details in this box.: +
 
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