Diaper Rash Physical Exam Documentation Form
Document findings and care details for a diaper rash physical exam. Please complete all relevant sections.
Patient Initials or ID
*
Exam Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Rash Location
*
Buttocks
Genital area
Thighs
Other
Rash Appearance
*
Redness
Raised bumps
Open sores
Scaling
Other
Rash Severity
*
Mild
Moderate
Severe
Associated Symptoms
Pain/discomfort
Itching
Fever
No additional symptoms
Other
Contributing Factors
Prolonged moisture
Irritant exposure (wipes, soaps, etc.)
Recent illness
Antibiotic use
Other
Assessment/Diagnosis
*
Care Instructions and Follow-up Plan
*
Submit Exam Documentation
Should be Empty: