Dermatology Intake Form: Fields Every Derm Practice Needs

Dermatology intake has a visual component that most specialties don't. A patient can describe a rash in a text field, but a photo is worth a thousand descriptors. The best dermatology intake forms combine structured clinical history with visual documentation, giving the provider a clear picture, literally, before the appointment begins.

Demographics and Contact Information

Standard fields: full name, date of birth, address, phone, email, emergency contact. Include preferred pharmacy, since dermatology frequently results in prescriptions sent directly to the patient's pharmacy.

Reason for Visit

What's bringing the patient in today? Common categories:

• Skin concern (rash, lesion, mole, acne, eczema, psoriasis)
• Skin check / annual screening
• Cosmetic consultation
• Follow-up on existing condition
• Surgical follow-up

Let patients select a category, then provide an open text field for details. Follow up with: how long has the concern been present, is it getting better or worse, and has it been treated before?

Photo Upload for Skin Concerns

This is the field that separates a generic intake from a dermatology-specific one. Let patients upload photos of their skin concern before the visit. Multiple photos from different angles and lighting conditions give the provider a head start on assessment.

Specify in the form instructions: close-up photo, wider shot for context, and a photo with a size reference (like a ruler or coin). A file upload field that accepts multiple images handles this cleanly.

For telehealth-heavy practices, this field is especially critical. The photos may be the primary visual data for the initial assessment.

Skin History

Questions specific to dermatology:

• Skin type: Fitzpatrick scale (I-VI) or simplified description (burns easily, tans easily, etc.)
• Sun exposure history: outdoor occupation, tanning bed use, sunburn frequency
• Skin cancer history: personal and family (melanoma, basal cell, squamous cell)
• Previous biopsies: location, date, results
• History of atypical moles
• Chronic skin conditions: eczema, psoriasis, rosacea, vitiligo, with onset and treatment history

Current Skincare Routine and Products

What patients put on their skin daily matters clinically:

• Cleanser, moisturizer, sunscreen (brand and frequency)
• Prescription topicals currently in use
• Over-the-counter treatments being used for the current concern
• Cosmetic products and makeup
• Recent changes to products or routine

This section reveals potential contact dermatitis triggers, product interactions, and treatment adherence patterns.

Medication History

Dermatology-critical medications to flag:

• Isotretinoin (Accutane): current or past use, including dates
• Immunosuppressants: increases skin cancer risk
• Blood thinners: relevant for biopsies and procedures
• Photosensitizing medications: tetracyclines, certain diuretics, NSAIDs
• Biologics: for psoriasis, eczema, or other conditions
• Oral contraceptives: relevant for hormonal acne management

Beyond specific flags, capture all current medications and allergies. Drug allergies are particularly important when prescribing topical or oral antibiotics.

Medical History

Relevant conditions: autoimmune disorders, diabetes (affects wound healing), HIV/immunocompromised status, thyroid conditions (associated with hair and skin changes), and pregnancy status (limits treatment options significantly).

Family history of skin cancer, melanoma, psoriasis, and eczema.

Insurance and Billing

Standard insurance fields, plus an important distinction: is the visit medical or cosmetic? This determines insurance billing and should be clear from the start. A patient coming in for acne is medical. A patient coming in for Botox is cosmetic. Some visits are both.

Consent

Consent for examination, consent for photography (clinical photos for the medical record), consent for procedures if applicable, and HIPAA privacy notice. E-signatures keep this clean.

Building a Derm Intake Form

Formisoft's photo upload field makes the visual documentation piece simple. Patients can upload multiple images directly from their phone camera. Combine that with the built-in medication and allergy fields, conditional logic for visit-type-specific questions, and e-signature for consent, and you have a complete dermatology intake in a single form.

The AI builder can generate the framework in seconds. Customize from there and send to patients before their appointment.

Start building with Formisoft, try it free.