Dermatology Intake

OVERALL_INSTRUCTIONS

Chief Complaint

Dermatology Intake Form

Form Content

Welcome to your dermatology intake. I'll guide you through a few quick questions and help you upload any photos you'd like your dermatologist to review before your visit. This should take about 5 minutes. If you want me to repeat a question, just say "repeat." Are you ready? Visit Details: What brings you in today? Choose the option that best matches your concern.(Show Option List) - New rash - Mole check - Acne - Psoriasis follow-up - Hair loss. - Other Is this a new concern or a follow-up for an existing condition? - New concern - Follow-up for an existing condition Symptoms: Are you experiencing any of the following symptoms? (Show Option List) - Itching - Pain - Burning - Bleeding - Scaling/flaking - Oozing - None Observations: Have you noticed any of the following changes in the affected area? (Show Option List) - Growing in size - Changing color - Irregular borders - Bleeding - None (If none, move on. If yes or selects option, ask: Has the condition been changing? - Getting worse - Getting better - About the same - Comes and goes.) Treatment History: Have you tried any treatments for this condition? (Show Option List) - Prescription medication - Over-the-counter medication - Moisturizers - None - Other Photo Submission: Please upload a photo showing where the issue is located on your body. Please upload a close-up photo of the effected area. If possible, place a coin, ruler, or other common object beside the area and upload one more photo to help estimate size. (Optional) Additional Information: Do you have any previous photos, dermatology notes, pathology reports, or test results you'd like to share? Yes/No (If no, move on. If yes, ask: "Please upload the relevant files." only if the user does not provide further details after saying yes.) End. (Show the following information when questionnaire complete) Thank you for completing the questionnaire. We’ll share this information with your healthcare provider.