Urticaria Physical Exam Documentation Form
Complete this form to document key findings and clinical context during a urticaria-focused physical examination.
Patient Initials
*
Date of Examination
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Duration of Symptoms (in days)
*
Description of Lesions (appearance, size, shape)
*
Distribution of Lesions
*
Localized
Generalized
Face
Trunk
Extremities
Other
Associated Symptoms
*
Itching
Angioedema
Fever
Respiratory symptoms
Other
Possible Triggers (select all that apply)
*
Food
Medication
Infection
Physical stimuli (pressure, cold, heat)
Other
Response to Prior Treatments
*
Physical Exam Findings (including vital signs if relevant)
*
Clinical Impression / Plan
*
Submit
Should be Empty: