Teledermatology referral form: RASH

For junior doctors, GP registrars, Nurse practitioners and locum GPs, the dermatological problem should be discussed with one of the Practice GP's before considering teledermatology referral. If applicable, please tick this box to confirm discussion has taken place prior to referral. 

Patient name	Full Name 	Patient Phone number	Patient Home Telephone 	
Patient DOB	Date of Birth 	GP Name	Usual GP Full Name 	
Patient address	Home Full Address (stacked) 	GP Surgery	Organisation Full Address (stacked) 	
Patient NHS number	NHS Number 	GP Phone number	Organisation Telephone Number 	
		GP Email	Organisation E-mail Address 	

Duration:	Features/morphology:	Rash symptoms:	
Days:      	Warty/rough	Itch	
Weeks:      	Elevated	Pain	
Months:      	Smooth	Mucosal involvement	
Years:      	Depressed	Genital involvement	
Persistent	Scaly	Asymptomatic	
Intermittent	Wet/exudative		
	Blanching		
Distribution:	Pustules	Course:	
Generalised/widespread	Vesicles/bullae	Rash worsening	
Localised (one area)	Scarring	Rash stable	
		Rash improving	

Site(s) of rash		
Suspected diagnosis?	     	
Nail signs
	     	
Genital symptoms or signs	     	
Mouth signs
	     	
Systemic symptoms	     	
Any treatments used/ response to treatments	     	
New medications started in last 6 months?	     	

Problems 
Family history

	     	
Occupation	     	
Alcohol intake	None, <14 units/week, 14-28 units/week, >28 units> week
 Single Code Entry: Alcohol consumption  	

Medication 
Allergies 

Ethnicity and skin type	     	
History of sun exposure	     	

Patient Performance Status
0: Patient able to carry out all normal activity	     	
1: Restricted in physically strenuous act	     	
2: Able to walk and capable of all self-care	     	
3: Capable of only limited self-care	     	
4: Completely disabled	     	
5: Not applicable	     	

Any other relevant Information