Fungal Nail Infection

What makes you think you have a fungal infection on your nails?
Kindly select your option

An examination by my doctor

An examination by a Podiatrist or Chiropodist

Self diagnosis

Are you currently receiving any treatment or under any medication?
Please provide more information of the medication being used if any.

Yes

No

If female or transmale, are you currently pregnant, breastfeeding or planning to do so?
Please select your option

Presently Pregnant

Presently Breastfeeding

Planning on getting pregnant

Neither Pregnant nor Breastfeeding

What is your biological gender?
Please select your option

Male

Female

Transmale (Born a female)

Transfemale (Born a male)

Can you relate to any of the following?
You have an underlying medical condition
You've been through a major surgical procedure
You have allergic reactions
You have cardiovascular conditions or might have had suffered a stroke
You suffer from a low liver or kidney function

Yes

No

Can you relate to any of the following?

Your hair loss started recently, and you've lost a lot of hair in less than four weeks.

Hair loss has occurred in irregular spots on your head.

Your scalp is itchy or inflamed.

You've lost your hair as a result of your pharmacological treatment.

You're completely bald or have lost all of your body hair.

Yes

No

Do you have a history of using Curanail/Loceryl or Amorolfine 5 percent Nail Laquer?
If so, which one did you use and how successful was it?

Yes

No

Are you experiencing any of the following?
Diabetes
A weakened immune system
Insufficiency of blood flow to the extremities
Peripheral arterial disease (PAD) is a condition that affects the
Cellulitis
Nails with thick, sharp edges cause injury to the surrounding skin of the affected area.
Do you require assistance?

Yes

No

Kindly upload a current image of the affected nail/nails
This question is not mandatory

Kindly elaborate to us how the affected nails look like
You can select mpre than one optionDiscolouration of the top and/or sides
Do you require assistance?

Change of color on the top and sides

Change in color at the base

Patches of white on the upper surface

Hardenned nails

Misshapen or scaly

Brittle and weak nails

Do you know how many finger nail/ toe nails are infected?
You can select more than one option
Do you require assistance?

Just one

About two

At most three

About four at least

Kindly identify for us which areas have been affected
You can select more than one option

Finger nails

Toe nails

Can we share this information with your General practitioner?
Providing us with your physician's address means that you allow us to share this information with him/her for updated medical records if need be. It also allows our clinician to access your medical records if there is a need for that. We advice you share this treatment with your doctor for him/her to update your medical records.

Yes

No

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