HS History Page

Patient Name *

Gender *

Do you consider your HS sympoms *

How was the diagnosis of HS made?

What was your age when the diagnosis of HS, or other problem was made?

What locations on your body are affected by HS or other dermatologic disease? *

Date of birth *

Age *

Email address *

Weight in lbs. *

Gender recommended or

Height in feet and inches *

Do you currently have a dermatologist?

Have you had any skin or wound cultures? *

Current medical history as it pertains to HS or other dermatologic or autoimmune disseases.

Please be as complete as you can

Have you had any surgery for HS? *

What medications are you currently taking for issues OTHER THAN HS? *

Medication Allergies *

Please list all your medication allergies and reactions

Do you have gluten or other food sensitivity? *

If so, please give the details

Have you ever been evaluated by a Functional Medicine Practitioner? *

Are you using any topical antibiotics for HS? *

Are you using any specific antiseptics or cleansers? *

Are you using any topical steroids? *

Are you currently taking any oral antibiotics specifically for HS or other skin problem?

Are you taking any injectable biologics? *

Such as Humira or Cosentyx

Has a dermatologist ever recommended a biologic, like Humira, but you declined? *

If so, please give us the details

Are you taking any other medications for HS? *

Here is where you can send us photos.

Drag & Drop Files, Choose Files to Upload You can upload up to 9 files.

It is helpful if we can see any areas that are currently, or previously, involved with HS or other skin problems. The link above explains exactly which photos we need.

Important: This form can only send about 20 MB total.

• Each photo should be about 1–2 MB
• Limit uploads to 3–5 photos per submission
• You may submit the form more than once if needed

iPhone users: If photos are too large, go to Settings → Camera → Formats → Most Compatible

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