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DEMOGRAPHICS

MY PERSONAL DETAILS

This information allow Dermal Health Science to track your progress and provide you with the best advice and insight.

Are you submitting this form for yourself or on behalf of a child?

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First Name

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Date of Birth

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Your age: years

Your child's age: years

Your child's age: months

MEDICAL BACKGROUND

ECZEMA HISTORY

Have you ever been diagnosed with atopic dermatitis / eczema by a medical practitioner?

Yes

No, but I think there may be symptoms of atopic dermatitis Eczema

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Have you ever used medication prescribed by a medical practitioner for atopic dermatitis / eczema?

Yes, but I'm not using presription products at the moment

Yes, I am currently using prescription products for my Atopic Dermatitis/Eczema

No

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Please select the medication you used, that was prescribed by your medical practitioner:

Topical cortisone cream / ointment

Oral cortisone medication

Topical antihistamine cream / ointment

Oral antihistamine medication

Over the counter emollient creams

A cream/ointment specially compounded (mixed) by the pharmacist

I can't remember which medication I used

I used medication not listed here

Please specify the medication you used:

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Over the last week, on how many days has your skin been itchy?

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Over the last week, on how many days has your skin felt dry and rough?

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Over the last week, on how many days have you had cracked or fissured skin?

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Over the last week, on how many days has your eczema kept you awake at night?

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Over the last week, on how many days has your eczema affected your ability to concentrate?

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Over the last week, on how many days has your eczema limited your choice of clothes?

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★ Judge.me Reviews

Let customers speak for us

94%

(6366)

4%

(263)

1%

(83)

0%

(12)

0%

(25)

N

Nicolene De Villiers

Amazing!

I love the inflacin serum. It helps so mich maintaining my skin in tip top condition. And it feels amazing on my skin. If I could rate it more than 5 stars, I would!

L

Dermatint

Lieze Labuschagne

Fantastic

Easy and quick to use one product instead of a sunblock as well as a foundation

Z

Rose Gold Lip Butter Ball

Zelda Jooste

Rose gold lip butter ball

This is my go to during all seasons of the year, it keeps my lips soft and it smells amazing. - I highly recommend this product and many more. - Zelda

C

Coleen Eva

Product feedback

I LOVE your products! The retinol serum has made a marked difference to my skin and my facial lines appear to have softened. Apert from the retinol, I particularly like the Collagen Serum.

C

Dermdefence SPF 50

Carmen Zeelie

Dermdefence SPF 50

H

Treatment Pack: Pigmentation

Heather Nel

Kick **** Pigmentation

Within 2 weeks I can see the difference in my pigmentation. Like always Dermexil never disappoints you.
👌THE BEST SKIN PRODUCT ON THE MARKET.👌
😁LOVE🌼🍃🌼LOVE😁

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