Pore House Patient Health Profile

1
What brings you here today?* This field is required.Select the concern that you'd like treatment for today. Your health and happiness is our top concern so we do not offer skin cancer screenings online.
Acne
Aging
Rash
Something else!
2
What state are you currently located in?* This field is required.Pore House is currently available in Connecticut and Massachusetts only.
Select State
Select State
Connecticut
Massachusetts
My state is not listed
3
Sorry, Pore House is currently available in Connecticut and Massachusetts only.Not in your neighborhood? Share your email below and we will let you know when we're in your area.
example@example.com
4
Meet Your Derm
5
Meet Your Derm
6
Create your account* This field is required.
First Name
Last Name
Phone Number
7
What is your email address?* This field is required.
example@example.com
8
What is your date of birth?* This field is required.
mm/dd/yyyy
9
Start your Pore House visit* This field is required.Your virtual dermatology visit is $65 and includes a custom treatment plan from a board-certified dermatology provider. You will have unlimited messaging access to your provider for 7 days after your first point of contact.
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ORDER SUMMARY
Total costUSD
Online Dermatology Consult
$65.00+
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First Name
Last Name
Credit Card Number
Security Code
Card Expiration
10
What is your address?
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
11
Terms and Conditions* This field is required.
12
Do we have your permission to text or email you outside of the patient portal?I consent to have Pore House communicate with me by email or text messaging regarding various aspects of my care. I understand that email and texts are not confidential methods of communication and may be insecure. I further understand that, because of this, there is a risk that email and text messaging might be intercepted and read by a third party.
Yes
No
13
What is your gender?* This field is required.We ask this question of all of our patients to ensure that we provide you with safe and effective care. We are inclusive of all identities.
Select
Select
Male
Female
Trans male / Trans man
Trans female / Trans woman
Genderqueer / Gender non-conforming
Different identity
14
What is your ethnicity?* This field is required.
Select
Select
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latinx
Native Hawaiian or Other Pacific Islander
White
Other
Prefer not to say
15
Are you currently pregnant, breastfeeding or planning to become pregnant?
Yes
No
16
What was the first date of your last menstrual period? * This field is required.
Date
Month
Day
Year
17
What is your current height and weight?* This field is required.
Height (ft)
Height (in)
Weight (lbs)
18
Do any of the conditions below apply to you?* This field is required.Check all that apply.
Asthma or lung disease
Asplenia
Autoimmune disorder
Blood clots
Cancer
Chronic gastrointestinal issues
Depression
Diabetes
Heart Disease
High cholesterol
Immunocompromised or immunocompromising medication
Medical condition requiring blood thinners
Migraines
Multiple Sclerosis
Renal failure
Seizure disorder
Stroke
Thyroid Condition
Other
None
19
Does anyone in your family have a history of any of the conditions below?Check all that apply.
Autoimmune disorder
Blood clots
Cancer
Depression
Multiple Sclerosis
None
20
Have you ever used any of the following oral medications for your skin?* This field is required.Check all that apply.
Doxycycline
Minocycline
Tetracycline
Erythromycin
Cephalexin / Keflex
Isotretinoin / Accutane
Birth control pills
Spironolactone
Other
None
21
Have you ever used any prescription or over-the-counter medications for your current concern?
Yes
No
22
Please tell us more about your previous treatments for your concern.When did you last use it, did it work for you, how did your skin react and why did you stop using it?
23
Are you currently taking any medications?* This field is required.This includes any medications, vitamins or dietary supplements (even if they're not related to your skin health!)
Yes
No
24
What medication(s) are you currently taking?* This field is required.Please list any medications, vitamins or dietary supplements that you take regularly, including the dosage.
25
Do you have any environmental or food allergies?* This field is required.
Yes
No
26
Do you have any allergies to medications?* This field is required.
Yes
No
27
Which medications are you allergic to?* This field is required.Please list the medication along with the associated reaction.
28
Are you open to taking oral medications (i.e. pills) if your provider thinks they would help?* This field is required.Oral medications are often used with topical medications to increase their effectiveness, but they have greater potential for side effects.
Yes
No
29
What pharmacy would you like us to send any prescriptions to?
Pharmacy Name
Pharmacy Zip Code
Yes
No
Would you prefer to have your prescriptions mailed to you if that is an available option?
30
What is your shipping address?Since you indicated you'd be interested in a mail-order pharmacy, what address should we ship to?
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
31
Are you interested in receiving nutrition and lifestyle recommendations as a part of your treatment plan?If so, we will ask a few additional questions about your lifestyle and wellness habits.
Yes
No
32
Tell us more about your lifestyle and wellness habits.At Pore House, we believe in a well-rounded approach to skin health which considers factors like nutrition, sleep, fitness, lifestyle and mental health when making a diagnosis and treatment plan.
Describe your current diet (i.e. gluten-free, dairy-free, low-carb, organic, vegetarian, etc.)
Do you ever experience constipation, diarrhea or bloating? Please explain.
Never
Sometimes (2-3 times per week)
Often (daily)
How often do you eat processed foods?
Never
Sometimes (2-3 times per week)
Often (daily)
How often do you exercise ?
Yes
No
Do you feel stressed or overwhelmed most days of the week?
How many hours of sleep do you get per night on average?
33
Write a message to your dermatology provider here. Tell them the reason for your visit in as much detail as possible.* This field is required.Don't forget to list any skincare products you currently use! You will get a chance to upload photos of your skin on the next step.
Huge
Large
Normal
Small
Ok
Ok
34
Upload photos of your skin for your provider to evaluate.* This field is required.Ensure that you photo is not blurry or dark, has not been edited or filtered and has been taken in the past 7 days.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Your photos and medical information are encrypted and stored securely through a HIPAA compliant platform. Only your doctor and care team have access to the medical information that you upload.
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