Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
Skin & Dermatology Assessment Form
Your information
Full Name *
Fitzpatrick Skin Phototype
Chief Dermatologic Complaint
Lesion Location
Lesion Morphology
ABCDE Criteria Evaluation
Additional details
Lesion Dimensions
Dermatologic History
Dermoscopic Findings
Please bring to your visit: clinical photo
Assessment & Treatment Plan
Provider Signature
Date
Skin & Dermatology Assessment Form template from formisoft.com. formisoft.com/intake-templates/skin-assessment