Scabies Treatment Intake Form
Please complete this form to help us evaluate and plan your scabies treatment. All fields are required for a comprehensive assessment.
Patient Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Preferred Contact Method
*
Phone
Email
Text Message
Other
Primary Concern or Reason for Visit
*
Symptoms Experienced
*
Itching
Rash
Redness
Blisters or bumps
Sores from scratching
Other
When did your symptoms begin?
*
Have you ever been diagnosed or treated for scabies before?
*
Yes, diagnosed and treated
Yes, diagnosed but not treated
No, never diagnosed or treated
Have you had close contact with anyone diagnosed with scabies or experiencing similar symptoms?
*
Yes, household member(s)
Yes, non-household contact(s)
No known exposure
Unsure
Current Medications or Treatments Tried
*
Known Allergies
*
Additional Notes or Questions
Submit
Should be Empty: