Free E Consultation by Regsor Psoriasis Solutions

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Name*

Age*

Gender

	Male
	Female

Geographical Location

Address

Email*

Have you been diagnosed for Psoriasis?

	Yes
	No

If yes, how long have you been diagnosed for Psoriasis?

Where did it first start?*

Did it spread slowly or was there acute exacerbation? (extent of lesions & symptoms)

Any Joint Pain?

	Yes
	No

Any Itchiness, Scaling, Erythema or Redness?

	Yes
	No

Any problem with palms or soles of feet?

	Yes
	No

Are nails, hands & feet affected?

	Yes
	No

Any lesions in scalp?

	Yes
	No

Any lesions in skin folds?

(armpit, between thighs, neck folds, infra memory area)

	Yes
	No

Any lesions in oral cavity or genitals?

	Yes
	No

Does it worsen with change in weather or environment?

	Yes
	No

Any problem related to diet?

(Does diet affect condition?)

	Yes
	No

Any other members in the family with similar problems?

	Yes
	No

Does it interfere with daily life?

	Yes
	No

Any history of Diabetes?

	Yes
	No

Does it induce stress or does stress worsen the condition?

	Yes
	No

Any other ailment apart from Psoriasis?

	Yes
	No

Are you currently being treated ?

	Yes
	No

If yes, please give details of medication taken

Any problems after treatment?

Provide any other information you may feel is relevant to your disease condition.