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Hydrocortisone 1% Cream – Mandatory Health Screening

Please answer every question so we can check this medicine is suitable. Your answers are used only to decide whether the medicine can be supplied, are reviewed by a pharmacist where needed, and are deleted after a fixed retention period.

eBay order number

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1. Who is the cream for?

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A

Myself

B

Someone else

2. Age of the person needing treatment

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A

10 years or older

B

Under 10

3. What area is affected?

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A

Small / localised patch

B

Face or genitals

C

Large or spreading area

4. What symptoms are present?

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Select all that apply.

Redness / irritation

Mild eczema flare

Mild dermatitis

Insect bite reaction

Other

5. Is the skin broken, weeping, infected, or very painful?

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A

No

B

Yes

6. Is this thought to be a fungal infection (ringworm, athlete’s foot, etc.)?

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A

No

B

Yes / unsure

7. Is the person pregnant or breastfeeding?

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A

No

B

Yes

8. Has the person ever reacted badly to steroid creams?

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A

No

B

Yes

9. Is the person using any other steroid creams at the moment?

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A

No

B

Yes

10. Do you agree to use the cream once or twice daily for no longer than 7 days?

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A

Yes

B

No

Use of your answers

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I agree to my answers being used to decide whether this medicine can be supplied and being reviewed by a pharmacist.

I agree