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Poison ivy / Contact dermatitis
Texas Telemedicine Doctor
Use this form is you are having a reaction to poison ivy or some other known allergen that gives you a rash
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Last name
*
Your answer
Date of birth
*
MM
/
DD
/
YYYY
How long have you had your rash?
Less than 1 week
1 - 4 weeks
More than 4 weeks
Other:
Clear selection
Do you know for certain that you were exposed to poison ivy or another allergen prior to the rash developing?
Yes, I know I was exposed
No, I do not remember being exposed
Other:
Clear selection
Where do you have your rash? (check all that apply)
Head and neck
Arms and hands
Legs and feet
Trunk
Other:
How would you describe your rash? (check all that apply)
Itchy
Blisters
Weeping
Redness
Other:
Is your rash spreading, improving, or staying the same?
My rash is spreading
My rash is improving
My rash is staying the same
Clear selection
If you have tried treating your rash, please tell me what you used and if it helped. If you have not, enter "None."
Example: I tried hydrocortisone cream from the pharmacy and it did not help
Your answer
If you have received treatments in the past that helped, please tell me what they were. If not, enter "None."
Example: Prednisone tapers have helped in the past
Your answer
Is there anything else about your condition that you would like me to know?
Your answer
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