Necessary Elements of a Dermatologic History and Physical Evaluation

Janet M. Cole, Deanna Gray-Miceli

Disclosures

Dermatology Nursing. 2002;14(6) 

In This Article

Demographic Information & History

Demographic Information

Usually collected at the front desk. Name, address, phone number, age, gender, ethnicity, marital status, occupation, education, and religious preference.

History

Chief Complaint. In patient's own words. The nurse gains a sense of direction about which triage questions to ask.

History of Present Illness. "OLDCARTS" - onset, location, duration, characteristics, associated symptoms, relieving factors, timing, severity; medications and treatments tried.

Medical history. General health, illnesses, surgeries, hospitalizations, blood transfusions, immunizations, emotional status, psychiatric history, medications, and allergies.

Family history. Do any other family members have the same condition, other skin conditions? Do parents, siblings, or children have cancer, diabetes, hypertension, heart disease, or stroke?

Health habits. Tobacco, alcohol, recreational drug use; diet, exercise, exposure to toxins; sexual exposures/habits.

Travel. Domestic and international in the last year.

Occupation. Although mentioned in the demographic section, it may be useful to review it here, especially if the symptoms seem to point to a contact dermatitis.

Hobbies. Gardening, crafts, etc. Skin care routines. Frequency and temperature of showers and baths; types of cosmetics, soaps, oils, and products used. Home remedies, sun exposure.

Hair and nail care. Products and routines.

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