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Evaluation & Management Form
Thank You for submitting the Dermatology New Problem History Form
Date
Name
Sex
M
F
Age
DOB
Tel
Drug Allergies & Special Considerations :
None
List
Constitutional-General Appearance:
Build, Nutrition, Posture, Grooming
Normal
Yes
No
Vital Signs Wt. Pulse, BP, Temp
Normal
Yes
No
Neuro/Psychiatric:
Alert & Oriented in T/S/P
Normal
Yes
No
Mood and Affect
Normal
Yes
No
Hair & Seat Glands:
Scalp & Body Hair
Normal
Yes
No
Eccrine & Apocrine Glands
Normal
Yes
No
Ear, Nose, Mouth & Throat:
Lips, Teeth and Gums
Normal
Yes
No
Oropharynx
Normal
Yes
No
Gastrointestinal:
No anal growths or fissures
Normal
Yes
No
No hepatosplenomegally
Normal
Yes
No
Eyes:
Eyelids and Conjunctivae
Normal
Yes
No
Neck:
Thyroid, nodules or masses
Normal
Yes
No
Cardiovascular(Peripheral):
No edema, Circulation ok
Normal
Yes
No
Extremities:
No digital cyanosis or clubbing
Normal
Yes
No
Lymph Nodes:
1-Neck 2-Axillae 3-Groin
Normal
Yes
No
Skin & Subcutaneous Tissues:
Head & Face
Normal
Yes
No
Neck
Normal
Yes
No
Chest, Breast & Axillae
Normal
Yes
No
Abdomen
Normal
Yes
No
Genitalia. Groin & Buttocks
Normal
Yes
No
Right Upper Extremity
Normal
Yes
No
Left Upper Extremity
Normal
Yes
No
Right Lower Extremity
Normal
Yes
No
Left Lower Extremity
Normal
Yes
No
Clinical History & Diagnostic Studies reviewed:
Clinical Impression
Follow Up
KOH
C & S
Bx
Surg
Workup
Ref
Management Plan
Follow Up
Days
Wks
Mths
PTC
PCP
REF
Chaperone & Scribe
Dermatologist
Pertinent Details (Photo &/or Audiovisual documentation) :
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