AKN Consultation This is not a formal consultation and it is not a substitute for an actual face-to-face history and examination by the doctor. Any response to an inquiry is tentative and subject to review after actual re-examination by the doctor. Note that any information submitted through this form is held in strictest confidence. Please fill out as much information as possible. (The * marked fields are required.)Name* First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Age*Gender*MaleFemaleEmail* PhoneHow did you hear about Dr Umar and AcneKeloidalisNuchae.com?GoogleYahooYouTubePress ReleaseOtherIf you chose Other, please specify below:Do you think you have acne keloidalis nuchae?YesNoDon't KnowOther / CommentIf yes, how was your acne keloidalis nuchae diagnosed?Have you had a biopsy?YesNoIf yes, what was your result?What are your symptoms? Pain Itch Bleeding Plus Discharge Other symptomsType of lesion. Choose one from the diagram below which one applies to you: Papules Nodules Merged Papules & Nodules Kelodial/Tiumor/Mass Flat Plague Distribution: Choose one area from diagram below which shows the distribution of your lesionsIIIIIIIVPast Treatments Have you done any past or ongoing treatments? Please provide any helpful information. MedicationInjectionsSurgeryLasersOtherList all other skin and scalp conditions you have: Facial Acne Body Acne Dissecting Cellulitis Folliculitis Decalvans Hidradenitis Supprativum Pilonidal Cyst or Sinus Facial Razor Bumps Keloids in other parts of the body? Location:Other conditions not listed aboveList all past and current medical problemsAre you currently being treated for any medical, surgical or psychological condition?What are your expectations from the procedure or treatment?Approximate date you would prefer to have your procedure: Please send some of your photos for better evaluation. Please send a photo that shows the full extent of your scalp involvement. If the lesions are covered with hair in some areas, shave the hair around the lesion before the photograph is taken. Photo #1Photo #2Photo #3Photo #4Would you want to subscribe to our newsletter? Sign me up! Leave a Reply Cancel reply
