TELEDERMATOLOGY DATA FORM

I. Clinical data A. Patient’s complaint (rason sa pagkonsulta):

______________________________________________________________ B. Brief description of lesion/s (maikling paglalarawan ng problems sa balat):

___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

C. Site/s affected (mga apektadong parte ng katawan): _________________________________________________________________________________

D. Associated symptoms (Is the lesion itchy or painful? Are there symptoms like fever, cough, colds, etc) [mga sintomas na kaugnay sa problema sa balat halimbawa, kati, sakit; at isa pang sintomas katulad ng lagnat, ubo, sipon, etc]: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

E. Duration (How long is/are the lesion/s? State in # of days or weeks or months or years) (gaano katagal ang problema sa balat, ilahad kung ilang araw/linggo/buwaan na): _________________________________________________________________________________

F. Precipitating factors (What might have triggered the skin lesions? E.g. heat, application of a cream, use of a new product, etc.) [ano sa tingin mo ang nagpasimula sa problems sa balat, halimbawa: naarawan o nainitan, may ipinahid na cream o ointment, may bagong produkto na nagamit]: __________________________________________________________________________________________________________________________________________________________________

G. Alleviating factors (What might have helped the skin lesions to resolve or improve? E.g. application of antibiotic or anti-inflammatory ointment or cream, intake of antihistamine, etc.) [ano ang nakapagpapawi o nakatulong sa problema or sintomas sa balat? halimbawa, naipahid na gamot nao may ininom na gamot]: __________________________________________________________________________________________________________________________________________________________________

H. Treatment used (What oral or topical medicine did you take/apply?) [ano ang iyong ininom o ipinahid na gamot, itukoy ang generic or brand?]: __________________________________________________________________________________________________________________________________________________________________

I. Change over time (Did the lesions improve, get worse, no change?) [may pinagbago ba ang problema sa balat?] _________________________________________________________________________________ _________________________________________________________________________________

J. Relevant (personal) past medial history (ibang personal na sakit)
 Allergy Asthma Diabetes Hypertension Pulmonary tuberculosis

Thyroid disease Acne Cancer (state specific CA) Others (state specific)


K. Any pre-existing skin conditions (may alam na ibang sakit sa balat): __________________________________________________________________________________________________________________________________________________________________

L. Medication history (Kindly list medications and supplementations i.e. vitamins, minerals, herbals, etc.) [pakilista ang mga gamot at bitamina o herbal na iniinom] ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

M. Relevant family history (mga sakit sa familya)
 Allergy Asthma Diabetes Hypertension Pulmonary tuberculosis

Thyroid disease Acne Cancer (state specific CA) Others (state specific)