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.) Full NameStreet AddressCityState/ProvinceZIP / Postal CodeCountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChina, People's Republic ofChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrance, MetropolitanFrench GuianaFrench PolynesiaFrench South TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island And Mcdonald IslandHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJohnston IslandJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarReunion IslandRomaniaRussiaRwandaSaint HelenaSaint Kitts and NevisSaint LuciaSaint Pierre & MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and South SandwichSpainSri LankaStateless PersonsSudanSudan, SouthSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwan, Republic of ChinaTajikistanTanzaniaThailandTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks And Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of America (USA)UruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis And Futuna IslandsWestern SaharaYemenZambiaZimbabweAgeGenderMaleFemaleEmail AddressPhoneSelectHow did you hear about Dr Umar and AcneKeloidalisNuchae.com?GoogleYahooYoutubePress ReleaseDo 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?PainItchBleedingPlus DischargeOther symptomsType of lesion. Choose one from the diagram below which one applies to you:PapulesNodulesMerged Papules & NodulesKelodial/Tiumor/MassFlat PlagueDistribution: Choose one area from diagram below which shows the distribution of your lesionsIIIIIIIVDistribution Past Treatments Have you done any past or ongoing treatments? Please provide any helpful information. MedicationInjectionsSurgeryLasersOtherList all other skin and scalp conditions you have:Facial AcneBody AcneDissecting CellulitisFolliculitis DecalvansHidradenitis SupprativumPilonidal Cyst or SinusFacial Razor BumpsKeloids 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. Upload your 4 photos hereDrag and Drop (or) Choose FilesSend Message Leave a Reply Cancel replyCommentEnter your name or username to comment Enter your email address to comment Enter your website URL (optional) Δ
