a. Date (dd/mm/yyyy) - [default to Today's date]
b. Consult ID [ automatically generated based on site and sequence of consults]

a. Patient's Last Name
b. Patient's First Name
c. Patient's MI
d. Patient's Date of birth
e. Patient's Phone #
f. Patient's Address
g. Unique Patient Identifier (e.g. SSN)
h. Insurance information [free text, may require multiple fields based on billing requirements of the organization]
i. Sex {M/F}
j. Ethnicity {Cau, Blk, Asian, etc}

a. Referring Physician name [Last name, first name]
b. Referring Physician ID
c. Referring Physician's Location/Site
d. Referring Physician's Phone #
e. Referring Physician' Fax #
f. Referring Physician's Email

a. Reason for Consultation {Pull down choices: Diagnosis, Second Opinion,
Recommendation for Treatment, Other (type in option)}
b. Patient's Chief Complaint {rash, growth, acne, nail, hair, other(type in option)}
c. Location(s) (free text or graphic image for point and click)
d. Duration {free text or pull down options to include "since birth"}
e. Chronicity {pulldown menu -intermittent, persistent, other(free text)}
f. Associated signs and symptoms {Pull down menu -Pruritus, Tenderness, Burning, other (type in option)}
g. Palliative factors (free text)
h. Exacerbating factors (free text)
i. Number of Images (integers)
j. PMHx (defaults to non contributory unless information is typed in as free text)
k. PSHx (defaults to non contributory unless information is typed in as free text)
l. Fam Hx (defaults to non contributory unless information is typed in as free text)
m. ROS (defaults to non contributory unless information is typed in as free text)
n. Medications (Defaults to None unless Free text is typed in )
o. Allergies (Defaults to NKDA unless text is typed in)
p. Biopsy results/ Laboratory data (Free text)
q. Provisional(Your) Diagnosis (Free text)
r. Specific Questions (Free text)

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If you are interested in participating in the Teledermatology Special Interest Group simply contact the chair of the SIG or email ATA at membership@americantelemed.org or call ATA at 202.223.3333.