Dermatology Mole Mapping Documentation

Dermatology Mole Mapping Documentation — Form Fields

This healthcare template includes 15 fields. Documentation form for full-body mole mapping and skin lesion tracking at dermatology clinics. Free to customize and use on ZenBuild.

• Patient Name (text, required)
• Patient ID (text, required)
• Date of Exam (text, required)
• Dermatologist Name (text, required)
• Skin Type (Fitzpatrick) (dropdown selection, required) — options: Type I (Very Fair), Type II (Fair), Type III (Medium), Type IV (Olive), Type V (Brown), Type VI (Dark)
• Total Moles Documented (number, required)
• New Moles Since Last Visit (number, optional)
• Changed Moles Since Last Visit (number, optional)
• Areas of Concern (checkboxes, optional) — options: Scalp, Face, Neck, Chest, Back, Arms, Hands, Legs, Feet
• Family History of Melanoma (multiple choice, required) — options: Yes, No, Unknown
• History of Sunburns (multiple choice, required) — options: Yes - Frequent, Yes - Occasional, Rarely, No
• Biopsy Recommended (multiple choice, required) — options: Yes, No
• Biopsy Location (if applicable) (text, optional)
• Clinical Notes and Recommendations (long text, optional)
• Dermoscopy Images (file upload, optional)