Skin Condition Record Form
Please provide detailed information about the skin condition to assist with assessment and follow-up.
Full Name
*
First Name
Last Name
Date of Record
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Email
*
example@example.com
Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Location of Skin Condition
*
Please Select
Face
Scalp
Arms
Hands
Torso
Legs
Feet
Other
Describe the appearance of the skin condition (color, size, shape, texture, etc.)
*
When did you first notice this condition?
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Symptoms experienced
*
Itching
Pain
Burning
Swelling
Bleeding
None
Other
How would you rate the severity of the condition?
*
Mild
1
2
3
4
5
6
7
8
9
Severe
10
1 is Mild, 10 is Severe
Have you had this condition before?
*
Yes
No
Possible triggers or causes (select all that apply)
Allergy
Contact with irritant
Infection
Medication
Stress
Unknown
Other
Please upload a clear photo of the skin condition
Upload a File
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of
Previous treatments or remedies tried
Additional notes or comments
Submit Record
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