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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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