Eczema

Do you have symptoms of eczema and/or dermatitis? This includes:

• Dry skin
• Small, raised bumps that may leak fluid and crust over
• Thickened, cracked, or scaly skin
• Intense itching, especially at night
• Red rash appearing shortly after exposure to an irritant or allergen

Are you currently breastfeeding?

Have you ever had an allergic reaction to hydrocortisone, chlorocresol or cetostearyl alcohol?

Are you allergic (hypersensitive) to any of the following:

• Dermol 500
• Benzalkonium chloride
• Chlorhexidine dihydrochloride
• Liquid paraffin
• Isopropyl myristate
• Cetostearyl alcohol

Are you experiencing any of the following skin conditions?

• Bacterial infection such as impetigo
• Viral infection such as cold sores or chickenpox
• Fungal infection such as athlete’s foot, ringworm or thrush
• Psoriasis

Are you taking any of the following medications?

• Oral anticoagulants
• Warfarin

Do you agree to the following?

• Not to apply Hydrocortisone cream to cracked or broken skin
• Only to apply a thin layer of Hydrocortisone to the affected area(s)

Do you agree to the following?

That emollients can be highly flammable when soaked into fabric (clothing, bedding, dressings, etc) and can become a fire hazard. Washing clothing and bedding may reduce product build-up but not totally remove it. You should not smoke or go near naked flames due to the risk of severe burns.

Do you agree to the following?

• You will read the patient information leaflet supplied with your medication
• You will contact us and inform your GP of your medication if you experience any side effects of treatment, if you start new medication or if your medical conditions change during treatment.
• The treatment is solely for your own use
• You have answered all the above questions accurately and truthfully. You understand our prescribers take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health.