THE

SKIN

CLINIC

QUESTIONNAIRE

Your
Age:

Name:

-

Occupation:

1. What is your skin problem? (rash, warts, itching, etc?)

2.Howlonghaveyouhadit?

3. Please
yourskinproblemislocated.Usean"X"orshadeinaffectedarea.'leaseCircle"YES"or"NO"andanswer1.Doyouhaveotherskinproblems?

mark

onJbe

(igure

where

e
."
2.Doesanyfamilymemberor

followini!

.
<.

relative

have

skin

problems?

S. Has another doctor given you anything for your skin?
- 4.-Have"y-Ou-used your skin? (like Penicillin, 6. Does anything
skincaUsearashorallergy?

anything

else on

Sulfa, which

others?) your
by

touches
0

7. Are you a doctor
8.Areyout.akiJi.g.myMEDICATIONS?

currenQ.y being treated for another problem?

(Pills,

capsules,

liquids,

can

be

prescription, over the counter, ere)
9. What creams, lotions, topica1s do you use? List all 10. Is there anything
knowaboutyourhealth?YESNOWhat?YESNOWhat?YESNOWhat?

None

YESNO.What?YESNOWhat?YESNOWhat?6.AreyouALLERGICtoanymedicine(s)YESNOWhat?

YESNOWhat?

Which

else I should

PLEASE
TURNPAGEOUER

YESNOWhat?

"IfIUstenlongenough,youwillte~lme

than
14.Do700haveafamilyhi.toryof:SkincancerIfyes,pleaaenitwhoaDdWhatkind1. 12.Doyouhaveafamil"hi8toryof:13.DoyoohaveapenonalhUttoryof: 11.DoyoubaveapenonaJhi8toryof:'A8~a.HvfeverEczema Illhouidknowaboutorwhichyouwanttorelate?.

Additionallnlormatiool

health

k

16. Arc there

If yeti, please

pUll

Are

you

or

If ye8, plea8e

the doctor.
problems?

any Dnulualetre81e8

hormone81

lilt?

nit.

p~,nant1
.

.
, .

YESNOIfthere'sanythingelseI.houldknowwhichwillhelpmetomeet.yourneedsbetter,pleasewrite'ithere'qrbeaure'totellmeaboutit.Moreoftenthannot,thepatientknOWIJwhatisgoinaronmoreac~telyandquicker

hi your

YE8NOB:Areyoutakin,BirthControl

Asthma

15. Are you eeem, any alternative or Complementary healen or practitioDen (Dot M.D.'e> for ekin or other

I.!um.Iu:2!!

Skin cancer

life that

.

Hayfever

'
YESNO YESNOfORtr°MENONLY:

Other
O~rCancer

what

Eczema

Cancer
1

Hivel

the diagnosis

Hive.

is."