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:
Reason for Submission of Case to Grand Rounds
Chief Complaint
History Of Present Illness
Past Medical History
Medications
Allergies
Family History
Social History
Physical Examination

LABORATORY TESTS
Date Exam Type
Findings
Date Exam Type
Findings
Date Exam Type
Findings

Date Exam Value Normal Range
DIFFERENTIAL DIAGNOSIS
Current Management Plan (excluding digital dermatology consult)
Treatment
Follow-up
Location of Digital Images: please specify the uniform resource location (URL)
JPEG images are preferred, up to 300 KB in size and with dimensions of 400 x 600 pixels

Image Security Information
User Name Password

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This document is a resource
from the Internet Dermatology Society
Send your comments to:
Rhett Drugge, M.D.
Last update: August 25, 1996