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Online Medical Questionnaire

*By completing this form in advance you can reduce the initial consultation time

This information is essential for your medical care, so please provide accurate details. The data you submit will be encrypted for transmission. If you have any questions while filling out the form, please do not hesitate to ask.

Today's Date

Essential Information

Information below, information is necessary information on medical law.

Please be sure to bring your passport

When registering for your appointment, passport verification is mandatory for identity confirmation. Please make sure to bring your passport with you

Please note that your reservation may be canceled If you do not bring your passport.

After identity verification, there will be no need for re-verification for the next six months

Thank you for your cooperation.

Name

Passport number

Tel

Please enter the address accurately where you will receive the medication.

Additional Information

How did you know The Roadledam?

Naver Search Ad

Naver Cafe

Naver Place

Naver Blog

Youtube(슬기로운 면역생활)

Daum kakao

SNS(Facebook, I.G.)

Outdoor Advertisement

Introduction by an acquaintance

Medical Condition Information

Please describe your current physical condition to the best of your knowledge.

Disease you want to be treated for

HPV

Cervical Dysplasia / CIN

Condyloma

Flat warts

Plantar Warts

Common Warts

Recrrent Resiratory Papillomatosis(RRP)

Molluscum Contagiosum

Other Skin Conditions (Seborrheic Dermatitis, Atopic Dermatitis, Acne, Nummular Eczema)

Please check all affected areas.

Scalp

Face

Neck

Chest

Abdomen

Back

Arms

Legs

Hands: Back of Hands, Palms, Fingers, Nails

Feet: Top of Feet, Soles, Toes, Toenails

Genitals

Anus

etc

If you have any additional information about the selected areas, please provide details.

Please list any known HPV types

When did the symptoms first appear?

Past Treatment Experience

Have received treatment

Diagnosed but never received treatment

Self-treated only

Please provide detailed information about past treatments

Please attach the test results (multiple attachments allowed).

Lifestyle Questionnaire

Please list any medications or supplements you are currently taking.

Please list any disease you have