What is the dermatology intake form template?
Skin appointments depend on detail: exactly where the problem is, how long it's been there, whether it itches or bleeds, and — for a mole — whether it has changed. This template collects that before the patient arrives, along with the history a skin clinic usually asks for, so the consultation can focus on the examination.
Patients start with their details and how they were referred, then tick "What would you like us to look at?" from a list that covers moles, rashes, acne, eczema, psoriasis, itching, hair loss, nail changes, hives, rosacea and full skin checks. They mark where on the body, how long they've had it and what it does. Ticking itch adds a 0–10 itch scale; choosing a mole or spot opens a short section, "Have you noticed any of these changes?". Up to four photos can be uploaded.
The history page asks what they've already tried, how their skin reacts to the sun, sun exposure, "Have you or a close family member had skin cancer?" and skin conditions in the family. Health conditions, medication, allergies, pregnancy, your clinic's information, a photo consent and a signature finish the form, and each intake is saved as a PDF in your FileIt vault with the photos attached.
- Best for
- Dermatology clinics, skin cancer screening services and GP skin clinics
- Filled in by
- The patient, before the first appointment
- Time to complete
- About 6 minutes
- Includes
- Concern and location, mole-change questions, photo upload, sun and family history, signature
Who uses a dermatology intake form?
- A skin clinic sends the form with every new-patient appointment
- A patient booking a mole check describes the changes they've noticed
- A teenager with acne lists the creams and tablets they've already tried
- A screening service collects sun-exposure history before full skin checks
- A patient with eczema uploads photos of a flare that may settle before the visit
- A private clinic gathers history and consent for teledermatology reviews
Questions on this dermatology intake form
27 questions over 4 pages · includes signature, file upload, conditional questions, multiple pages, consent checkbox, ratings.
1 Your details
- Your name*
- Date of birth*
- Mobile*
- Email*
- How were you referred? Self-referral · My doctor · Another specialist · Skin screening service · Other
2 Your skin concern
- What would you like us to look at?* A mole or spot · A rash · Acne · Eczema or dermatitis · Psoriasis · Itching · Hair loss · Nail changes · Hives · Rosacea · A full skin check
- Where on your body?* Scalp · Face · Neck · Chest · Back · Arms · Hands · Abdomen · Legs · Feet · Genital area · All over
- How long have you had it?* Less than 2 weeks · 2 weeks to 3 months · 3–12 months · More than a year · As long as I can remember
- Does it… Itch · Hurt or feel tender · Bleed · Crust or weep · Come and go · Get worse in the sun · None of these
- How itchy is it? asked only when it applies
- Have you noticed any of these changes?* asked only when it applies Getting bigger · Changing shape · Changing colour · Uneven edges · Raised or lumpy · Bleeding or not healing · New in the last year · No changes
- Photos of the area
- How much does it affect your daily life?
3 Treatments & history
- What have you tried already? Moisturisers or emollients · Over-the-counter creams · Prescribed creams or ointments · Antihistamines · Antibiotics · Tablets from a specialist · Light therapy · Nothing yet
- Names of treatments and how well they worked asked only when it applies
- How does your skin react to the sun without protection? Always burns, never tans · Usually burns, tans a little · Sometimes burns, tans gradually · Rarely burns, tans easily · Very rarely or never burns
- Sun exposure Work outdoors · Lived in a hot climate · Severe sunburn in the past · Used sunbeds · None of these
- Have you or a close family member had skin cancer?* No · Yes, me · Yes, a close family member · Yes, both · Not sure
- What type, and when? asked only when it applies
- Skin conditions in your family Eczema · Psoriasis · Acne · Many moles · Allergies or asthma · None that I know of
4 Health & consent
- Other health conditions
- Medication you take
- Allergies
- Are you pregnant, planning a pregnancy or breastfeeding? No · Pregnant · Planning a pregnancy · Breastfeeding · Not applicable
- Photos
- My information*
- Signature*
The dermatology intake form, page by page
1 Your details
Required name, date of birth, mobile and email, and an optional "How were you referred?" — self-referral, doctor, another specialist, a skin screening service or other.
2 Your skin concern
The required checklists "What would you like us to look at?" and "Where on your body?", and the required "How long have you had it?". "Does it…" asks whether it itches, hurts, bleeds, crusts, comes and goes or gets worse in the sun; ticking itch shows a 0–10 "How itchy is it?" scale. Choosing a mole or spot adds a heading and a required list of changes — bigger, shape, colour, edges, raised, bleeding, new or no changes. Then an optional upload for up to four photos and a 0–10 scale for the effect on daily life.
3 Treatments & history
"What have you tried already?" opens a box for treatment names and how well they worked. Then "How does your skin react to the sun without protection?", sun exposure, the required "Have you or a close family member had skin cancer?" (which asks the type and when if it's the patient) and skin conditions in the family.
4 Health & consent
Other health conditions, medication (including the pill and supplements), allergies and "Are you pregnant, planning a pregnancy or breastfeeding?". A placeholder paragraph for your clinic information, an optional photo consent, a required declaration that the information is correct, and the patient's signature.
Make the template yours
- Replace the placeholder paragraph with how your clinic stores and uses photos
- Trim the concern list to the conditions your clinic treats
- Add a cosmetic-treatment page if you also offer aesthetic services
- Make the photo upload required for remote or teledermatology reviews
- Change the body-area list to match your own body map
- File intakes in a vault folder per clinician
Tips for a better dermatology intake form
- Ask for a close-up and a wider photo so the location is clear
- Remind patients to note when a mole changed, not just that it did
- Use emailed requests to see which patients haven't filled it in before the day
- Read the pregnancy and medication answers before planning treatment
- Search the Responses table by name when a patient calls with questions
Every response becomes a PDF in your vault
Each intake is saved as a signed PDF in your vault. Uploaded photos appear in the PDF and are also filed as attachments of the document at full size. The clinic is emailed and the patient can be sent a copy.
The Responses table lists new patients by submission date, and the CSV export gives you a sortable list for planning clinic sessions.
- Start from this template. It opens in the FileIt Forms designer — change any question, add pages, set the rules for when questions appear.
- Share it. Turn on a public link, or send it to people by email, each with their own link. They don’t need a FileIt account.
- Get the answers as PDFs. Each response is saved as a PDF in the vault folder you choose, with uploaded files attached — and listed in a Responses table you can export to CSV.
Dermatology intake form: frequently asked questions
Is this dermatology intake template free?
Yes. It's one of the starter templates in the FileIt Forms app on every account, and every question can be edited.
Can patients upload photos of their skin?
Yes. The concern page accepts up to four JPG, PNG or HEIC photos. They're printed in the PDF and filed as attachments of the vault document.
Why do the mole questions only appear sometimes?
They're shown only when the patient ticks "A mole or spot", so people coming for acne or a rash aren't asked about mole changes.
Does the form assess the skin problem?
No. It only collects information for the clinician to review.
Can I add my clinic's policies?
Yes. Replace the placeholder paragraph on the last page with your own text.
Do patients need a FileIt account?
No. They fill it in from a link or an emailed request.