Folliculitis Symptom Report Form
Report your symptoms for folliculitis to assist with assessment and care.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
When did your symptoms begin?
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Which areas of your body are affected?
*
Scalp
Face
Neck
Arms
Legs
Trunk
Buttocks
Other
How would you rate the severity of your symptoms?
*
Mild
1
2
3
4
5
6
7
8
9
Severe
10
1 is Mild, 10 is Severe
Please describe the appearance of the affected area(s) (e.g., redness, pus, bumps):
*
Have you noticed any factors that make your symptoms better or worse?
Heat
Sweating
Shaving
Friction
Antibiotic creams
Other
Have you tried any treatments? If yes, please specify.
Do you have any of the following medical conditions?
Diabetes
Immunosuppression
Chronic skin conditions
None of the above
Other
Please upload a clear photo of the affected area (optional):
Upload a File
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