Atopic Dermatitis Form

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Full Name

HSN Number

DOB

Select a gender

Contact Number

Patient Information

Allergies

Pregnant

Breastfeeding

Family history of atopic dermatitis or previous diagnosis with atopic dermatitis

Recent contact with person with similar rash (consider other conditions, e.g. scabies, pediculosis)

Recent contact with plant or exposure to chemical

Medical History

Recently started a new drug (topical or other route)

Recent sun exposure while taking a photosensitizing drug

Recent 2 week course of prescribed topical corticosteroid and symptoms have not resolved

Drug History

Are any red flag symptoms or symptoms of severe atopic dermatitis present?

Moderate or severe lesions on faceSigns of secondary infection (bacterial, fungal, viral)Palms of hands or soles of feet affectedPersistent pruritus +/- excoriationsWidespread lesions (> 30% of body surface area)Major impact on sleep, daily activities or well-beingBleeding, oozing , crackingExtensive skin thickening +/- pigment changesYesNo

Are symptoms typical of mild to moderate atopic dermatitis?

Pruritus – hallmark symptomDry skinLocalized patches of redness, scaling, excoriations (scratches)Weeping, crusting vesiclesLittle/no impact, to moderate impact on sleep, daily activities or well-beingYesNo

Location of the lesion(s):

Review of Symptoms