Skin Rash Physical Exam Form
Complete this form to document the clinical evaluation of a patient's skin rash. All responses pertain to the current examination.
Patient Full Name
*
First Name
Last Name
Date of Exam
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Rash Location / Body Area
*
Please Select
Face
Neck
Trunk
Arms
Legs
Hands
Feet
Generalized (multiple areas)
Other
Onset and Duration of Rash
*
Symptom Severity
*
Mild
1
2
3
4
5
6
7
8
9
Severe
10
1 is Mild, 10 is Severe
Rash Appearance
*
Please Select
Macular
Papular
Vesicular
Pustular
Plaque
Urticarial
Erythematous
Scaling
Other
Associated Symptoms
*
Itching
Pain
Burning
Swelling
Fever
None
Other
Known Triggers or Exposures
Current Medications or Treatments Tried
Clinician Notes or Exam Findings
Submit Exam
Should be Empty: