Dermatology Patient Intake

Dermatology Patient Intake — Form Fields

This healthcare template includes 8 fields. Gathers skin health history and current concerns for new dermatology patients. Free to customize and use on ZenBuild.

• Patient Full Name (text, required)
• Date of Birth (text, required)
• Primary skin concern / reason for visit (text, required)
• Skin conditions (check all that apply) (checkboxes, optional) — options: Acne, Eczema / Dermatitis, Psoriasis, Rosacea, Suspicious mole / lesion, Hair loss
• How long have you had this skin condition? (dropdown selection, required) — options: Less than 1 month, 1–6 months, 6–12 months, More than 1 year
• Have you used any topical treatments previously? (multiple choice, required) — options: Yes, No
• List any topical or oral medications currently used for skin (long text, optional)
• Family history of skin cancer? (multiple choice, required) — options: Yes, No, Unknown