Registration - Clinic Psoriasis

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Registration

First Name:

Middle Name:

Last Name:

Username:

E-mail:

Password:

Verify Password:

City:

State:

Country:

What is your Present Age?:

Please indicate your gender:

Male Female

Kind of Psoriasis Condition:

Your Age when Psoriasis First Appeared:

State (in number of years) Age of your Current Psoriasis Condition:

Severity Level of your Current Psoriasis Condition:

How Stable is your Current Psoriasis Condition:

How your Psoriasis condition behave after the end of every flare up period?:

Get Worst

Remains Same

Not Applicable

WHAT CAUSED YOUR PSORIASIS TO START?:

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

Select parts of your body which are covered with psoriasis at present?:

Other Body areas not listed above:

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

Is there any pus formation in your liesons?:

No Pus

Regular Pus Formation

Pus with Bleeding

Tell us about Itching if present?:

No Itching	Itching spell starts during day time only	No medication is effective on my Itching
Mild and Occassional Itching	Itching spell starts at night only
Severe and Untolrable Itching spells	Using cream or medicine stops itching for few hou
Itching spell stards any time	Using cream or medicine stops itching for few days

What is the condition of your Nails:

My Nails are clean and Flat

My Nails are pitted

My Nails are deformed and raised

Tell us in detail about your nail condition:

At what age Psoriasis Arthritis (PA) developed:

At which Joint PA developed first?:

Select all Joints effected by PA at present:

State whether you are Vegetarian or Non Vegetarian:

Vegetarian Non Vegetarian

Describe in detail food items you eat in every meal:

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

If taking any medication for constipation, heart burn or any other digestion problem? Please provide details.:

Temperature and Climate conditions of your city:

What part of the year do you see aggression or flare up in your psoriasis condition:

Summer Time

Winter Time

No Change

What is the nature of job you are doing?:

What is the level of your job stress:

Very Stressfull

Somewhat Stressfull

No Stress

Any other stress conditions?:

Are you taking any kind of stress medical? Please provide details:

Do you do exercises/yoga?:

Regular

Occassional

Never

Do you have psoriasis in your family? Please provide details.:

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:

Group II - Herbal and Natural Products such as Slippery ELM, Herbal Teas, Coal Tar, Pagano Diet, and other similar products. Select all Applicable:

Group III - Homeopathy Treatment. Select all Applicable:

Group IV - Dead Sea Salt Treatment. Select all Applicable:

Group V - Other Soft OTC Products. Select all Applicable:

Group VI - Steroid based prescription drugs. Select all Applicable:

Group VII - Vitamin D based treatment such as Dovanex. Select all Applicable:

Group VIII - Steroid and Vitamin D combination products such as Taclonex. Select all Applicable:

Group IX - UV Radiation based therapies. Select all Applicable:

Group X - Methotrexate, Cyclosporin, Acitretin or other similar prodcuts. Select all Applicable:

_UE_MH_METHOTREXATE_NAME:

Group XI - Biologics based treatments such as Enbriel, Reptiva, Remicade etc. Select all Applicable:

_UE_MH_BIOLOGICS_NAME:

Any other detail you want to provide regarding different treatments you used in the past.:

Do you have problem of Falling Hair? If yes, Please provide detail here.:

Do you have problem of Dandruf? If yes, Please provide detail here.:

Do you have problem of Hypertension? If yes, Please provide detail here.:

Do you have problem of High Blood Pressure? If yes, Please provide detail here.:

Do you have problem of Depression? If yes, Please provide detail here.:

Do you have problem of Cardiac Heart Disease? If yes, Please provide detail here.:

Do you have problem of Asthma? If yes, Please provide detail here.:

Do you have problem of Thyroid? If yes, Please provide detail here.:

Do you have problem of Kidney? If yes, Please provide detail here.:

Do you have problem of Severe Indigestion? If yes, Please provide detail here.:

Do you have problem of Bowl Movement Syndrome? If yes, Please provide detail here.:

Do you have problem of Chronic Soar Throat? If yes, Please provide detail here.:

Do you have problem of Diabetes? If yes, Please provide detail here.:

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?:

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

Are you suffering from the problem of erectile dysfunction?:

Yes

In general do you feel satisfied after performing sexual act?:

Yes

In general do you feel your partner is satisfied after performing sexual act?:

Yes

Any other detail you want to provide about your sexual life.:

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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