Dermatology Intake Form Template

A dermatology appointment turns on three things a general intake form never asks: where the concern is, how long it has been there, and how it has changed since it started. This template asks those first, then covers symptoms, sun and sunbed history, family history of skin cancer, everything currently going on the skin, and what has already been tried and did not work. There is a link field for photos taken over time, with guidance on adding an Upload field instead if you would rather patients attach them directly.

Use this template

Last updated 21 August 2026

Fields in this template

Patient Full Namerequired
Date of Birth
Email Addressrequired
Phone Number
What Is the Main Skin Concern You Want Seen?required
Where on Your Body Is It?required
Face · Scalp or hairline · Neck · Chest, back or shoulders · Arms or hands · Abdomen or trunk · Legs or feet · Nails · Genital or groin area · Widespread or several areas
If You Ticked Several Areas, Which One Bothers You Most?
How Long Have You Had It?required
Less than 2 weeks · 2 to 6 weeks · 6 weeks to 6 months · 6 months to 2 years · More than 2 years · As long as I can remember · I'm not sure
How Has It Changed Since It Started?required
Getting bigger or spreading · Getting darker or changing colour · Changing shape, or the edge has become uneven · Raised, thickened or become lumpy · Staying about the same · Getting better on its own · It comes and goes
Which of These Apply Right Now?
Itching · Pain or soreness · Burning or stinging · Bleeding, weeping or oozing · Crusting or scaling · Swelling · A new mole, or a mole that has changed · A sore that has not healed · Hair loss or thinning · Nail changes · None of these
Describe the Concern in Your Own Words
Link to Photos of the Area
How Much Time Do You Spend in Strong Sun?
Rarely — I'm mostly indoors · Occasionally — weekends or holidays · Often — regular outdoor activity or sport · Daily — I work or train outdoors
Have You Ever Had a Blistering Sunburn?
Yes, more than once · Yes, once · No · I'm not sure
Have You Ever Used a Sunbed or Tanning Bed?
Yes, regularly at some point · Yes, occasionally · No · Prefer not to say
Do You Use Sunscreen?
Daily, all year · On sunny days or when outdoors · Rarely · Never
Has Anyone in Your Immediate Family Had Skin Cancer?
Yes — melanoma · Yes — another type of skin cancer · Yes — but I don't know which type · No · I don't know · Prefer not to say
What Do You Currently Put on Your Skin?
What Have You Already Tried for This Concern?
Current Medications
Allergies and Reactions
Do Any of These Apply to You?
I am pregnant or breastfeeding · I have a condition that affects my immune system · I am taking medication that suppresses my immune system · I have had radiotherapy or phototherapy to the skin · I have diabetes · I have had a skin cancer removed before · None of these · Prefer not to say
What Would You Like to Get Out of This Appointment?
Before You Submitrequired
I understand this form is used to prepare for my appointment, that it is not a diagnosis, and that my skin will be assessed by a clinician at the appointment itself.

Who uses this template

Dermatology clinics and private practicesDermatologists and dermatology nurse specialistsSkin cancer and mole-check clinicsTeledermatology and photo-review servicesHospital dermatology outpatient departmentsGP practices running a skin clinicMedical aesthetics clinics with a clinician-led consultation

About this template

A dermatology intake form is not a general patient intake form with a skin question added. The clinical history that matters for skin is spatial and temporal: which part of the body, how long, and what has changed. This template puts those three questions first and makes body area a multi-select, because a rash on the hands and the feet is a different problem from a rash on the hands alone, and a single free-text box loses that distinction the moment it is written.

After that come the exposures and the history that change how a lesion is read — sun exposure and blistering sunburn, sunbed use, sunscreen habit, and family history of skin cancer, which ships optional with a prefer-not-to-say option. Products and previous treatment are asked as two separate fields on purpose: what someone currently puts on their skin and what they have already tried for this specific concern are different lists, and merging them tends to lose the one that saves appointment time — the treatment that did nothing, or made it worse.

Photographs are handled honestly. The template collects a link rather than an attachment, because a seeded template cannot ship an upload field, and the field description tells the practice how to add an Upload field in the form editor instead — formformform supports file uploads on any form at up to 2 MB per file, encrypted alongside the rest of the answers on a form with end-to-end encryption switched on. Skin photographs are sensitive, so the copy also says the quiet part: decide where they will be stored, and for how long, before you ask for them. formformform hosts every form in the EU and handles submissions under GDPR; end-to-end encryption is opt-in per form and freezes once the first response arrives. Using this template does not make a practice compliant with HIPAA or any other regime, and nothing here is a diagnosis or a triage tool.

14 form ideas you can build with this template

Medical Dermatology New Patient Intake

Collect the presenting skin complaint, its duration and its change over time before a first consultant appointment.

Mole and Skin Check Pre-Visit Form

Record which mole has changed, how it has changed, sunbed and sunburn history, and family history of melanoma before a skin check.

Acne Clinic Intake Form

Capture affected areas, current skincare products and every acne treatment already tried, so the consultation starts past what has already failed.

Eczema and Dermatitis Intake Form

Gather flare pattern, itch and weeping symptoms, contact exposures and emollient or steroid history before a first appointment.

Psoriasis Clinic Intake Form

Record extent across body areas, nail and scalp involvement, and previous topical or phototherapy treatment.

Rosacea Consultation Form

Collect facial involvement, burning and stinging symptoms, sun exposure habits and every product currently used on the face.

Hair Loss Consultation Intake

Ask about scalp and hairline involvement, duration, pattern of change, medication and family history in one preparation form.

Nail Disorder Consultation Form

Use the nail symptom option and the body-area multi-select to record which nails are affected and for how long.

Paediatric Dermatology Intake (Parent-Completed)

Let a parent describe a child's rash, its spread and what has been applied to it, with the emergency instruction visible at the top.

Teledermatology Pre-Consultation Form

Pair the history questions with a photo link so a remote clinician has both before the video call starts.

Skin of Colour Dermatology Intake

Use the free-text description field so patients describe changes in their own words rather than against options that assume one skin tone.

Occupational Skin Complaint Intake

Record hand and forearm involvement, what makes it worse, and products used at work for a suspected work-related dermatitis.

Post-Treatment Skin Review Form

Reuse the change-over-time and symptom questions to record how an area has responded since the last appointment.

Clinician-Led Aesthetic Consultation Screening

Collect skin history, medication, pregnancy status and previous treatments before a clinician assesses whether a treatment is appropriate.

What's included

Body area ships as a multi-select, so a concern in several places is recorded as several places rather than one sentence

Duration and how the concern has changed are separate required questions — change over time is what a dermatologist reads first

A symptom checklist covering itch, pain, bleeding, crusting, spreading, non-healing sores, hair and nail change

Sun exposure, blistering sunburn, sunbed use and sunscreen habit asked as four short questions rather than one vague one

Family history of skin cancer separated into melanoma and other types, and it ships optional

Two separate free-text fields for products currently used and treatments already tried, because they are different answers

A photo link field with an https:// placeholder, plus instructions for adding an Upload field in the editor

Pregnancy, immune status and previous skin cancer collected as one optional checklist with a prefer-not-to-say option

An emergency instruction at the top of the form, not buried in the confirmation

How to create a dermatology intake form

1
Click "Use this template" to load the dermatology intake form into your free formformform account.
2
Edit the body-area options to match how your clinic records sites — some practices split left and right, or use a body-map notation the front desk already understands.
3
Decide whether date of birth should be required. It ships optional; switch it to required if you match records on it.
4
Replace the photo link field with an Upload field in the editor if you want photographs attached directly, and set your retention rule for them before you publish.
5
Turn on end-to-end encryption for the form in your account settings if you want answers, and any uploads you add, sealed to your key before they are stored.
6
Add the branching you want in the editor — for example, revealing the nail questions only when Nails is ticked. Templates cannot ship conditional logic, so add it after cloning.
7
Check the emergency wording at the top against the urgent pathway you actually offer, and name it.
8
Publish and send the link with the appointment confirmation, far enough ahead that someone can take photos before the visit.

Best practices for your dermatology intake form

Ask for change before appearance. Duration and how a lesion has changed are the two questions that separate a routine review from an urgent one, which is why both ship required and the free-text description does not.

Keep body area a multi-select. Collapsing it to one text box costs you the pattern

hands and feet together, or scalp and neck together, is information the sentence loses.

Leave family history optional. It genuinely changes how a changing mole is assessed, but a patient who does not know their family history should not be blocked from submitting, and one who does not want to say should not have to.

Do not ask for photographs until you know where they will live. Photographs of skin are identifiable and sensitive. Set a retention period, decide who can see them, and say so on the form before you switch the link field for an Upload field.

Separate what is used from what has been tried. Merging the two loses the failed treatments, and the failed treatments are what stop the appointment repeating them.

Add the branching in the editor. Nail questions for nail concerns, scalp questions for hair loss

the editor supports conditional logic even though a seeded template cannot carry it.

Say what happens next on the form. A line about who reads the intake and when means fewer follow-up calls asking whether it arrived.

Never present the form as triage. It is preparation for an appointment. Keep the emergency instruction at the top, name your real urgent pathway in it, and do not imply that a fast answer here replaces one.

Turn on end-to-end encryption before you publish, not after. Encryption is opt-in per form and freezes once the first response arrives, so decide before the first patient submits.

Do not claim compliance. EU hosting and GDPR handling are real and can be stated. SOC 2 and ISO 27001 belong to the hosting provider, and no form makes a practice HIPAA compliant.

Frequently asked questions

Is this dermatology intake form template free?

Yes. Use it, customise it and collect unlimited submissions at no cost, with no per-submission fees.

How is this different from the general patient intake form?

The general intake form collects identity, insurance and a broad medical history. This one is built around a skin complaint: body area as a multi-select, duration, how the concern has changed, a skin-specific symptom checklist, sun and sunbed history, family history of skin cancer, and what has already been tried. If you need both, send the general intake once and this one before the dermatology visit.

Can patients attach photos of their skin?

This template ships with a link field rather than an attachment, because a seeded template cannot include an upload field. formformform does support file uploads on any form, up to 2 MB per file — add an Upload field to your copy in the form editor. On a form with end-to-end encryption switched on, uploaded files are encrypted along with the answers.

Should photographs be encrypted?

If you collect them, treat them as identifiable clinical data. formformform offers optional end-to-end encryption per form: switch it on and each answer, and any file uploaded, is sealed in the patient's browser to your public key before it is stored. It is opt-in and it freezes once the first response arrives, so enable it before you publish.

Why is family history of skin cancer optional?

Because a patient who does not know it should still be able to submit, and one who would rather not answer should not be forced to. It matters clinically, which is why the field explains why it is asked rather than simply demanding an answer.

Can I use this for a teledermatology consultation?

Yes, and the photo field is the reason it works for one. Pair it with the telehealth consent form so consent for a remote consultation is recorded separately from the clinical history.

Does this form diagnose skin conditions or assess cancer risk?

No. It collects history so a clinician can prepare. It does not score, triage or diagnose anything, and the form says so above the submit button. Anything urgent should go to an emergency number or an urgent care service, not to a form.

Is this form HIPAA compliant?

No template makes a practice HIPAA compliant. formformform hosts in the EU, handles submissions under GDPR and offers optional end-to-end encryption; whether your overall workflow meets HIPAA or any other regime is for you and your compliance advisers to determine.