Cold Sore Form

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Full Name

HSN Number

DOB

Select a gender

Contact Number

Patient Information

Allergies

Pregnant

Breastfeeding

Renal impairment (CrCl)

Immunocompromised due to disease state (HIV, malignancies, etc.)

Had the patient previously had a cold sore?

YesNo> 6 episodes/year

Medical History

Immunocompromised due to medication (e.g. high dose corticosteroid, chemotherapy, certain biologics)

Drug History

Any red flag symptoms present?

Signs / symptoms of systemic illness (fever, swollen glands, etc.)Lesion present for more than 14 daysLesion on or around the nose, or ocular involvementYesNo

Are symptoms of current or past episodes typical of a cold sore?

Unilateral vesicular lesion surrounded by erythemaLesion appears on border of the lipVesicles break open leaking a clear, sticky fluid and heal with no scarring within 7-10 daysYesNo

Have lesions appeared?

YesNoNo : prodromal symptoms (itching, tingling or burning, redness at site) and history of cold sores

Review of Symptoms