Confidential Questionnaire for Herpes

Sex: Female Male

Age:

Skin Color:

Weight: (pounds)

How long have you suffered from Herpes?

Just Started 1 to 5 years 6 to 10 years over 10 years All my life

 

Which part of your body is affected?

Scalp Face Arm Leg Hand Foot Body

 

What type of Herpes do you have?

Your skin problem is:

Mild Moderate Severe

 

What kind of symptoms do you have?

Itching Inflamation Dry Skin Sores Redness Scaly Rash
Nausea Fever Burning GI Problem Bumps Hives Swelling
Pain Heat Boils Hair Loss Shiny Skin Pain Blistering
Irritation Discharge or Bleeding Mood Changes Skin Discoloration
Bloating Thick Patches Lack of Moisture Sleeplessness
Flu-like sypmtoms Blisters with oozing and crusting

 

Do you have any allergy, food intolerance or sensitivity?

Yes,  what kind?
No

Do you take any prescription and/or non-prescription drugs?

Yes,  what kind?
No

Do you have any family member who has Dermatitis?

Yes  No

Have you tried any alternative treatments?

Yes,  what kind?
No

Our QuikCure health and wellness team can customize your regimen (diet, lifestyle, detox) to uncover the true source of your problem. Would you like more information about this service? Yes  No

 

How did you hear about us?


Please Specify: (such as Google, WebMD, etc..)

Please add any comments and questions you have below:

This form is not designed to treat, diagnose, or cure any disease, condition or illness. It is not meant to replace attention by a medical doctor. However, our health and wellness team can answer your questions, customize your regimen, and choose the right products that work best for you.