Dermatology Grand Rounds Research Form |
A signed Photographic Consent Form is required for study enrollment |
Date of Submission: | Referring Physician(s): | ||||
Date of Birth: | Sex: | Race: |
Chief Complaint |
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History Of Present Illness |
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Past Medical History | |
Medications | |
Allergies | |
Family History | |
Social History |
Physical Examination |
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LABORATORY TESTS |
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Date Exam Type |
Findings |
Date Exam Type |
Findings |
Date Exam Type |
Findings |
Date | Exam | Value | Normal Range |
DIFFERENTIAL DIAGNOSIS |
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Current Management Plan (excluding digital dermatology consult) |
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Treatment |
Follow-up |
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Location of Digital Images: please specify the uniform resource location (URL) |
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JPEG images are preferred, up to 300 KB in size and with dimensions of 400 x 600 pixels |
Image Security Information | |||
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User Name | Password |
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