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719 West Hamilton Ave, Eau Claire, Wisconsin 54701
(715) 832-1044
About Us
About Dr. Steven C. Immerman
About Dr. Richard Daniels
Dr Immerman’s Credentials
Our Surgeons
Our Staff
Patient Testimonials
1000 Patient Satisfaction Survey
Our Clinic
Consultation
Billing & Insurance
Eau Claire, Wisconsin
OakLeaf Surgical Hospital
Notice of Provider Privacy Practices
Diagnosis
Pilonidal Cysts
What Causes Pilonidal Disease?
Glossary of Pilonidal Terminology
Pilonidal Disease
Pilonidal Sinus
Hidradenitis and Pilonidal Disease
Pain from Pilonidal Cysts
Treatment
Cleft-Lift Procedure
Pilonidal Operations
The Definitive Guide to Pilonidal Abscess
Pilonidal disease with minimal symptoms
Help! I just had a wide excision!
Why didn’t my doctor tell me about the cleft-lift procedure?
Why Isn’t My Wound Healing?
Home Treatments
Pre and Post Op Care
How long to stay and how to travel
Pre-Operative Preparation
What to Bring for Surgery
Nutrition for Healing
Post-Operative Care
Activity Instructions after a Cleft Lift Procedure
Clothing for Pilonidal Patients
Post-Operative Pilonidal Wounds and Drainage
“Hacks” for Healing after Pilonidal Surgery
Pain after Pilonidal Surgery
For Clinicians
Emergency Room and Urgent Care Providers
Wound Clinics and Pilonidal Disease
Surgeons
Blog
Contact Us
About Us
About Dr. Steven C. Immerman
About Dr. Richard Daniels
Dr Immerman’s Credentials
Our Surgeons
Our Staff
Patient Testimonials
1000 Patient Satisfaction Survey
Our Clinic
Consultation
Billing & Insurance
Eau Claire, Wisconsin
OakLeaf Surgical Hospital
Notice of Provider Privacy Practices
Diagnosis
Pilonidal Cysts
What Causes Pilonidal Disease?
Glossary of Pilonidal Terminology
Pilonidal Disease
Pilonidal Sinus
Hidradenitis and Pilonidal Disease
Pain from Pilonidal Cysts
Treatment
Cleft-Lift Procedure
Pilonidal Operations
The Definitive Guide to Pilonidal Abscess
Pilonidal disease with minimal symptoms
Help! I just had a wide excision!
Why didn’t my doctor tell me about the cleft-lift procedure?
Why Isn’t My Wound Healing?
Home Treatments
Pre and Post Op Care
How long to stay and how to travel
Pre-Operative Preparation
What to Bring for Surgery
Nutrition for Healing
Post-Operative Care
Activity Instructions after a Cleft Lift Procedure
Clothing for Pilonidal Patients
Post-Operative Pilonidal Wounds and Drainage
“Hacks” for Healing after Pilonidal Surgery
Pain after Pilonidal Surgery
For Clinicians
Emergency Room and Urgent Care Providers
Wound Clinics and Pilonidal Disease
Surgeons
Blog
Contact Us
HS, Skin and Autoimmune Disease History Form
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HS, Skin and Autoimmune Disease History Form
Please enable JavaScript in your browser to complete this form.
Please enable JavaScript in your browser to complete this form.
Patient Name
*
Gender
*
Do you consider your current HS symptoms
*
Severe
Moderate
Mild
No symptoms at present
Was the diagnosis of HS made:
*
By a dermatologist
By a primary care physician
Self Diagnosed
Other
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
*
What is the best email(s) for us to communicate with you?
Weight in lbs.
*
For this type of surgery we need to know your height and weight.
Height in feet and inches
*
Do you currently have a dermatologist?
*
If so, please tell us their name and location.
Have you had any skin or wound cultures?
*
If so, please give us the details.
Medical History
and Email on
Current medical history as it pertains to HS or other dermatologic or autoimmune disseases.
*
Have you had any surgery for HS?
*
If so, what are the details?
What medications are you currently taking for issues OTHER THAN HS?
*
Medication Allergies
*
Please list all medication allergies or any medications to which you have had side effects. If you are unable to swallow pills, let us know.
Do you have gluten or other food sensitivity?
*
Have you ever been evaluated by a Functional Medicine Practitioner?
*
Questions about treatment for HS or other dermatologic issues.
Please answer each of these important questions. If they don't apply to you just answer "none" or "N/A".
Are you using any topical antibiotics for HS?
*
Clindamycin
Mupirocin ointment
Erythromycin
Dapsone
None
Other
Are you using any specific antiseptics or cleansers?
*
Benzoyl peroxide wash
Chlorhexidine wash
Phisohex
None
Other
Are you using any topical steroids? Such as:
*
Hydrocortisone
Triamcinolone
None
Other
Are you currently taking any oral antibiotics specifically for HS or other skin problem?
*
Doxycycline or minocycline
Clindamycin
Rifampin
none
Other
Are you taking any injectable biologics?
*
If you are taking Humira, Cosentyx, Remicade, Tremfya, Skyrizi, or anything similar, please let us know what you are taking, how long you have been taking it, and if has seemed to help.
Has a dermatologist ever recommended a biologic, like Humira, but you declined?
*
If so, please explain.
Other medications for HS
*
Are there any other medications you are taking for HS or other dermatologic conditions that have not been mentioned?
we need to see photos of any areas, such as groins or armpits involved with HS or other skin problems.
This is where you attach photos to this form.
Important: The maximum size of this email form can only be 20 MB. If the photo sizes add up to more than this, the form will not come through. It would be best to make sure the photos are about 1-2 MB each, or that you submit the form more than once with a smaller number of attached images (if you have a lot of photos to share). The above link has some tips on how to make photos smaller.
Drag and drop you jpg photos here.
Drag & Drop Files,
Choose Files to Upload
You can upload up to 6 files.
Total size of file uploads can not exceed 20MB.
DON'T FORGET TO HIT THE SUBMIT BUTTON WHEN YOU ARE FINISHED.
Submit
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