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Discipline

: General

Sub Discipline

: test

Document Title

: Dermatology Clerking Note - Occupational Dermatoses/ Contact Dermatitis

HISTORY

Employment History

Current Job Title

Employers Address

History

Chief Complaints

History Of Present Complaint

Systemic Review

Fever/Weight Loss/ Lost Of Appetite

Hair And Nail Changes

Cardiovascular System (CVS)

Respiratory

Gastrointestinal

Genitourinary

Central Nervous System

Ent/Eye

Musculoskeletal

Others, Specify

Underlying Medical Problems

Atopic dermatitis

YesNoNot sure

Allergic Rhinitis

YesNoNot sure

Bronchial Asthma

YesNoNot sure

Chronic obstructive airway disease

YesNoNot sure

Others, specify

Drug History

Current Medications

Supplements

Traditional

Allergies And Alert

Family History

Occupational Information

Current Job

Since When?

Duration

Working Hours

Job Description

Any Form Of Personal Protective Equipment?

Skin Lesions Since When?

Skin Lesions Improved During Holidays/Weekends?

Similar Skin Lesions Among The Colleagues?

Others, Specify

Other Jobs

Since When?

Duration

Working Hours

Job Description

Previous Jobs

Please Update Method

Other Relevant History

Household Activities

Cleaning

Cooking

Gardening

Pets

Others, specify

Hobbies

Social History

Smoke

Alcohol

Recreational drug use

Chewing tobacco

Others, specify

Examination

General Description

PROBLEM LIST

Problem List

DIAGNOSIS

Diagnosis

Contact Dermatitis Allergens Suspected

Animal hair, fur, skin

Barber/hairdressing material, perm, color

Chemical (others)

Color paints

Construction material eg cement, tile adhesive

Coolants (car/machine)

Cosmetic, cream, sunblock

Dental material and prosthesis eg amalgam

Detergent, cleaning material

Disinfectants

Furniture

Gloves (leather, rubber, latex)

Glue

Hearing aid, glasses, contact lens

House dust

Jewelry

Laboratory chemical

Metal

Music instrument

Office supplies

Osteosynthesis implant (metal, bone cement)

Perfume, aftershave

Pesticide, herbicide, insecticide

Petrol solvent

Plant

Plastic material

Raw food and additives

Rubber

Softener

Tattoo

Textile

Toy

Weapons

Woods

Others, specify

MANAGEMENT

Orders

Others, Specify

Counseling

YesNo

By Who

Notification Done

YesNo

Referral

Outgoing Referrals

Plan

SIGNATURES

Notes Component

HISTORY
PROBLEM LIST
DIAGNOSIS
MANAGEMENT
SIGNATURES

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