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  • Skin Clinic Patient Questionnaire

    Enviado por

    JaeChick08
    838 visualizações2 páginas
    This three question skin clinic questionnaire asks about the patient's skin problem, medical history, and current medications. Specifically, it asks about: 1) The location and description of the skin problem 2) How long they have had the skin problem and if any family members also have skin problems 3) Their current medications and any allergies or medical conditions

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    Direitos autorais

    © Attribution Non-Commercial (BY-NC)

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    This three question skin clinic questionnaire asks about the patient's skin problem, medical history, and current medications. Specifically, it asks about: 1) The location and description of the skin problem 2) How long they have had the skin problem and if any family members also have skin problems 3) Their current medications and any allergies or medical conditions

    Direitos autorais:

    Attribution Non-Commercial (BY-NC)
    Baixe no formato PDF, TXT ou leia online no Scribd
    Sinalizar o conteúdo como inadequado
    838 visualizações2 páginas

    Skin Clinic Patient Questionnaire

    Enviado por

    JaeChick08
    This three question skin clinic questionnaire asks about the patient's skin problem, medical history, and current medications. Specifically, it asks about: 1) The location and description of the skin problem 2) How long they have had the skin problem and if any family members also have skin problems 3) Their current medications and any allergies or medical conditions

    Direitos autorais:

    Attribution Non-Commercial (BY-NC)
    Baixe no formato PDF, TXT ou leia online no Scribd
    Sinalizar o conteúdo como inadequado
    de 2

    THE SKIN CLINIC QUESTIONNAIRE

    Your Name:

    Age: - Occupation:

    1. What is your skin problem?


    (rash, warts, itching, etc?)
    2.Howlonghaveyouhadit?
    3. Please mark onJbe (igure where
    yourskinproblemislocated.Usean"X"orshadeinaffectedarea.'leaseCircle"YES"or"NO"andanswer1.Doyouhaveotherskinproblems?
    e followini!
    YESNOWhat?
    ." .

    <.
    2.Doesanyfamilymemberor
    YESNO.What?YESNOWhat?YESNOWhat?6.AreyouALLERGICtoanymedicine(s)YESNOWhat?
    relative have skin problems?

    S. Has another doctor given you


    anything for your skin?

    - 4.-Have"y-Ou-used anything else on


    your skin?

    (like Penicillin, Sulfa, others?)

    6. Does anything which touches your


    skincaUsearashorallergy?
    0

    7. Are you currenQ.y being treated by


    a doctor for another problem?
    8.Areyout.akiJi.g.myMEDICATIONS?
    (Pills, capsules, liquids, can be
    prescription, over the counter, ere)
    9. What creams, lotions, topica1s do
    you use? List all None Which

    10. Is there anything else I should


    YESNOWhat?
    knowaboutyourhealth?YESNOWhat?YESNOWhat?YESNOWhat?
    PLEASE
    TURNPAGEOUER
    "IfIUstenlongenough,youwillte~lme
    14.Do700haveafamilyhi.toryof:SkincancerIfyes,pleaaenitwhoaDdWhatkind1.
    12.Doyouhaveafamil"hi8toryof:13.DoyoohaveapenonalhUttoryof:
    11.DoyoubaveapenonaJhi8toryof:'A8~a.HvfeverEczema
    than
    Illhouidknowaboutorwhichyouwanttorelate?.
    Additionallnlormatiool
    k
    health
    healen

    pUll
    Are
    16. Arc there

    or
    you
    If yeti, please

    the doctor.
    If ye8, plea8e
    15. Are you eeem,

    problems?

    hormone81
    lilt?

    nit.

    p~,nant1
    or practitioDen

    .
    ,
    any Dnulualetre81e8
    any alternative

    .
    YESNOIfthere'sanythingelseI.houldknowwhichwillhelpmetomeet.yourneedsbetter,pleasewrite'ithere'qrbeaure'totellmeaboutit.Moreoftenthannot,thepatientknOWIJwhatisgoinaronmoreac~telyandquicker
    YE8NOB:Areyoutakin,BirthControl
    hi your
    Asthma

    I.!um.Iu:2!!
    .
    or Complementary

    life that
    Skin cancer

    '
    (Dot M.D.'e> for ekin or other
    Hayfever

    O~rCancer
    Other

    YESNO
    YESNOfORtr°MENONLY:
    what
    Eczema

    Cancer
    1
    Hivel

    the diagnosis
    Hive.

    is."

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