You are on page 1of 2

YourName:

Age: -

THE

Occupation:

SKIN

CLINIC

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

QUESTIONNAIRE

it? 2. How long have you had 3. Please mark onJbe (igure where problems? your
it? 2. How long have you had
3.
Please
mark
onJbe
(igure
where
problems? your skin problem is located. Use an "X" or shade in affected area. 'lease Circle "YES"or "NO" and answer 1. Do you have other skin
e
followini!
What? YES NO
."
.
<.
or 2. Does any family member
What? YES NO . What? YES NO What? YES NO What? 6. Are you ALLERGIC to any medicine(s) YES NO
relative
have
skin
problems?
S. Has another
anything
doctor
given
you
for your
skin?
- 4.-Have"y-Ou-used
anything
else
on
your
skin?
(like
Penicillin,
Sulfa,
others?)
6. Does
anything
which
touches
your
allergy? skin caUse a rash or
0
7. Are
you
currenQ.y
being
treated
by
a doctor
for
another
problem?
MEDICATIONS? 8. Are you t.akiJi.g .my
(Pills,
capsules,
liquids,
can
be

9.

prescription,

What creams,

over the counter, ere)

lotions,

topica1s

do

you use?

List all

None

Which

10. Is there

anything

else I should

What? know about your health? YES NO What? YES NO What? YES NO

PLEASETURN OUER PAGE

kind1. 14. Do 700 have a family hi.tory of: Skin cancer If yes, pleaae nit who aDd What

hUttory 12. Do you have a famil" hi8tory of: 13. Do yoo have a penonal

of:

Eczema 11. Do you bave a penonaJ hi8tory of: 'A8~a. Hvfever

If yeti,

please

lilt?

Asthma

Hayfever

Skin cancer

Cancer

O~r

Other

Eczema

Cancer

1

Hivel

Hive.

15.

Are

you

eeem,

any

alternative

or

Complementary

 

healen

or

practitioDen

(Dot

M.D.'e>

for

ekin

or

other

health

problems?

 

If ye8,

plea8e

nit.

16.

Arc

there

any

Dnulualetre81e8

hi your

life

that

k

than

Additionallnlormatiool

me "If I Us ten long enough, you will te~l

Are

pUll

the

you

or

p~,nant1

hormone81

doctor.

.

.

,

.

YES

quicker NO If there's anything else I .hould know which will help me to meet. your needs better, please write'it here'qr be aure 'to tell me about it. More often than not, the patient knOWIJ what is goinar on more ac~tely and

Control YE8 NO B: Are you takin, Birth

.

I.!um.Iu:2!!

'

YES

NO

ONLY: YES NO fORtr°MEN

what the diagnosis is."