Wood’s Lamp Examination Form
Document the details of a Wood’s lamp skin examination accurately and thoroughly.
Patient Name
*
First Name
Last Name
Date of Examination
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Body Area Examined
*
Please Select
Face
Scalp
Neck
Trunk
Arms/Hands
Legs/Feet
Other
Reason for Examination
*
Pigmentation assessment
Suspected infection
Evaluation of lesion
Other
Observed Finding / Fluorescence
*
Lesion / Skin Description
*
Duration of Concern
*
Please Select
Less than 1 week
1–4 weeks
1–6 months
More than 6 months
Prior Treatment or Products Used
Additional Notes
Examiner Name and Signature
*
Submit
Submit
Should be Empty: