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Discipline

: General

Sub Discipline

: test

Document Title

: Dermatology Phototherapy Request Note

Procedure Ordered

Performing Staff

Date Of Birth

Address

Contact No.

Ethnic Group

Marital Status

Occupation

Working Hours

Source Of Referral

Brief History

Age Of Onset

Date Of Diagnosis

Duration Of Illness

Biopsy Performed

YesNo

TYPE OF PHOTOTHERAPY

Type Of Phototherapy

Treatment Frequency

PSORIASIS

Type

Percentage Of Skin Involved

VITILIGO

Site Involved Method

Please Update Method

ATOPIC ECZEMA

Percentage Of Skin Involved

Site Involved

Face

Upper Limbs

Lower Limbs

Trunk

Others, specify

MYCOSIS FUNGOIDES

Type

Percentage Of Skin Involved

Site Involved

Face

Upper Limbs

Lower Limbs

Trunk

Others, specify

MORPHOEA /SCLERODERMA

Extent

Percentage Of Skin Involved

Site Involved

Face

Upper Limbs

Lower Limbs

Trunk

Others, specify

CHECKLIST FOR CONTRA INDICATIONS

Checklist For Contra Indications

Please Update Method

Clinical Examination

OTHER INDICATION

Other Indication

SIGNATURES

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