Fungal Nail Infection Consultation FormPlease complete this confidential form. Our clinician will review and respond shortly. Name * First Name Last Name Date Of Birth * MM DD YYYY Gender * Male Female Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Phone * (###) ### #### How many nails are affected? * 1 2-3 More than 3 All Nails Which nails are affected? * Fingernails Toenails Both How long have you had the infection? * Less than 3 months 3–6 months Over 6 months What do your nails look like? * Thickened Discoloured Crumbly Lifting Other Have you had a diagnosis confirmed by a doctor or test? * Yes – confirmed fungal test Yes – visual diagnosis only No Are you under 18 or over 75 years old? * Yes No Do you have diabetes or poor circulation in your feet? * Yes No Have you recently had unexplained bleeding, weight loss, or other symptoms? * Yes No Have you been diagnosed with a skin condition such as psoriasis that may mimic nail fungus? * Yes No Have you used any treatments for this before? * Yes- topical Yes- oral No If yes, what treatments have you used and did they work? Do you have a preference for treatment type? * Oral tablets Topical lacquer Unsure – need advice Do you have liver disease or have you ever had liver function problems? * Yes No Are you pregnant, planning to become pregnant, or breastfeeding? * Yes No Are you currently taking any of the following: amiodarone, statins, antidepressants, antipsychotics, anticoagulants, or antibiotics? * Yes No Please list any current medications you’re taking Do you have any allergies to antifungal medication (e.g. terbinafine, itraconazole)? * Yes No Consent & Understanding * I understand treatment may take several months and that nails may take time to improve. I agree to have blood tests through my GP if oral antifungal tablets are recommended. I understand that topical treatment may be preferred if only one or two nails are affected. I confirm that all the information I’ve provided is accurate. I consent to this information being reviewed by a prescribing clinician. Thank you. A clinician will review your answers shortly. You may be asked to complete further tests before treatment is prescribed.
