832-849-1914
info@ucftexas.org
Home
Our Services
Covid 19 testing
Covid-19-Vaccination
Tele-Healthcare
Men’s Health
Women’s Health
Dietitian /Nutrition
Mental Wellness And Behavioral Health
Early Health Screening
Diagnostic/Lab
Radiology
Training And Education
Community Development
Referrals to Reliable Healthcare Providers
Imaging & Radiology
Screening
Mobile Phlebotomy
Primary Healthcare
Community Development
Outreach Event
Health Fair
Internships
About Us
Forms
Cilent Intake
Eligibility Form
Policy Form
Patient Form
Evaluation Form
Skin Screening Program
History Form
Login
Donate Now
Skin Screening Program
Thank You for submitting the Dermatology New Problem History Form
Date
Name
Sex
M
F
Age
DOB
Tel
Drug Allergies & Special Considerations :
None
List
Date of Previous Visit:
Previous Medical Records Reviewed and Updated
No
Yes
Chief Complaint:
Same
New
Please Complete a New Problem Form:
Spot
Growth
Acne
Itching
Rash
Other Please
History of Present Illness:___Problem-1
Diagnosis
Treatment
Status
Clear
Better
Same
Worse
Other
Problem-2
Diagnosis
Treatment
Status
Clear
Better
Same
Worse
Other
Problem-3
Diagnosis
Treatment
Status
Clear
Better
Same
Worse
Other
Please List any changes in the following categories since your previous visit:
Drug & Allergy History
None
Yes
Please List
Drug & Allergy History
None
Yes
Please List
Drug & Allergy History
None
Yes
Please List
Drug & Allergy History
None
Yes
Please List
Drug & Allergy History
None
Yes
Please List
Drug & Allergy History
None
Yes
Please List
Drug & Allergy History
None
Yes
Please List
Any Other Questions or Comments
None
Yes
Please List