Fungal Skin Infection Intake Form
Please complete this form to help us evaluate your suspected fungal skin infection. All information is confidential and will assist in your assessment.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
What symptoms are you experiencing?
*
Itching
Redness
Scaling or flaking
Rash
Blisters
Cracking or peeling skin
Discoloration
Other
Which area(s) of your body are affected?
*
Feet (e.g., between toes)
Groin
Armpits
Hands
Nails
Scalp
Face
Other
How long have you had these symptoms?
*
Less than 1 week
1–4 weeks
1–3 months
More than 3 months
Have you had any recent exposures that may increase your risk?
*
Close contact with someone with a skin infection
Use of public showers or locker rooms
Participation in sports involving skin contact
Recent travel
Use of communal towels or equipment
None of the above
Have you used any treatments for this condition?
*
No treatment used
Over-the-counter antifungal cream
Prescription medication
Home remedies
Other
Do you have any known allergies?
*
No known allergies
Medication allergies
Skin product allergies
Other allergies
Do you have any of the following medical conditions?
*
Diabetes
Weakened immune system
Chronic skin conditions (e.g., eczema, psoriasis)
None of the above
Please provide any additional information or concerns about your skin condition.
Submit
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