Identifying Information

Gather the patient's general identifying data.

Chief Complaint

Elicit the patient's chief complaint.

History of Presenting Illness (HPI)

Characterize each of the patient's skin lesions using the OPQRST/OLD CARTS approach.
Specific histories based on Chief Complaint:

Mole Changes

Change in size, shape or colour (ABCDE screen for melanoma)

  • A: Asymmetry
  • B: Border irregularity
  • C: Colour change
  • D: Diameter > 6mm
  • E: Evolution (change in last 6 months) (can include itch or new bleed, not just size/shape evolution)

Consider blistering sunburn before age 20

Skin changes or lesions

  • Pruritic or painful
  • Bleeding or non-healing
  • Ocular or mucous membrane involvement
  • Provoked by sun? Is it seasonal?
  • Constitutional symptoms:
    • Weight loss
    • Malaise
    • Fever
  • Response to any previous treatments (topical or systemic)
Skin Type Description
I White, very fair, always burns
II White, fair, burns more than tans
III White, tans more than burns
IV Dark brown (e.g. Mediterranean skin), rarely burns, tans with ease
V Dark brown (e.g. Middle Eastern skin), tans easily, very rarely burns
VI Black, never burns, tans easily

Hair changes (scarring or non-scarring)

  • Focal or diffuse
  • Slow or rapid
  • Does the hair break off or fall out at the root
  • Are menstrual periods regular or irregular
  • Acne or hirsutism
  • Shedding or gradual thinning

Nail changes

  • Associated skin findings (e.g. tinea pedis, psoriasis, lichen planus)
  • Number of nails involved
  • Number of hands and feet involved
  • Present from birth
  • Nail polish use
  • Trauma (picking/rubbing cuticles, friction induced ex: runner's toe)
  • Consider anemia

Past Medical History (PMHx)

  • Skin diseases
  • Autoimmune disease (e.g.diabetes, connective tissue disorders)
  • Allergies or atopic diseases
    • Asthma
    • Eczema
    • Allergic rhinitis/hay fever
  • Cancer
  • Any hospitalizations or surgeries
  • Recent viral illness
  • Prior skin biopsies
  • Exposure history
    • Water contamination
    • Toxins
    • Medications and drugs, including
      • Over-the-counter
      • Supplements
      • Herbal products
      • Immunizations
    • Detergents and soaps
    • Skin, hair, nail products
    • Employment, hobbies, chance of home exposure (see social history)

Family History (FmHx)

  • Skin diseases (e.g., psoriasis)
  • Other people itchy in household
  • Autoimmune diseases (e.g. vitiligo, lupus)
  • Allergies or atopic diseases
    • Asthma
    • Eczema
    • Allergic rhinitis/hay fever
  • Cancer (especially melanoma)

Social History (SocHx)

Specifically ask about:

  • Occupation and occupational exposures (e.g. cement workers, florist)
  • Sexual orientation and practice
  • Hobbies (e.g. sun exposure, travel, pets)
  • Travel History
  • Stressors

Substance Use History (SubHx)

Specifically ask about:


Gather complete list, but specifically ask about:

  • Oral contraceptive pills




Note immunizations and ensure they are up to date in the patient's record.

Review of Systems

Conduct a review of systems, keeping other etiologies from your differential in mind.


  1. Bickley L, Hoekelman R. Bates’ Guide to Physical Examination and History Taking. Philadephia, Pa: Lippincott; 2009.
  2. James W, Berger T, Elston, D. Andrews' Diseases of the Skin: Clinical Dermatology. 10th ed. Saunders; 2005.
  3. Hunter JC, Savin J , Dahl M. Clinical Dermatology. 3rd ed. Massachusetts: Wiley-Blackwell; 2002.
  4. Freiman A, Barankin B. Derm notes: Dermatology Clinical Pocket Guide. F. A. Davis Company; 2010.