Skin, Rash, & More Visit
  • Date of Birth*
     - -

  •
  • Format: (000) 000-0000.
  • What was your gender at birth?*

  • You should NOT use Omnia TeleHEALTH if you are experiencing an emergency. Emergencies include but are not limited to:

    • Severe or unusual chest pain
    • Severe shortness of breath
    • Symptoms of a stroke (such as facial drooping, arm weakness, or speech difficulties)
    • Thoughts of harming yourself or others
  • ARE YOU EXPERIENCING AN EMERGENCY? IF YOU ARE EXPERIENCING AN EMERGENCY, CALL 911 OR GO TO AN EMERGENCY ROOM IMMEDIATELY.*
  • Please select what you need to be treated for today:*


  • A streak of band extending from the affected area could indicate a serious infection. The streak of band may be warm, slightly raised or swollen. It can show up as redness in lighter skin tones and darker than surrounding skin in darker skin tones. 

  • Are there streaks or bands extending from the affected area?*

  • Color in the affected area that is sprading rapidly, within minutes or hours, could be a sign of a serious infection or allergic reaction. 

  • Is the color in the affected area spreading rapidly?*


  • Some rashes are caused by an allergy or contact with something irritating to the skin. The following questions will help identify a possible cause of your skin condition.

  • Just before the symptoms started, was there contact with any of the following? (Select ALL that apply)*
  • What was the new food that you ate?*

  • ATHLETE'S FOOT VISIT

  • When did your symptoms start?*
  • What is the color of the affected area? (Select ALL that apply)*
  • Do you have a rash on the skin that resembles a target or a bruise?*
  • Have you had a recent tick bite?*
  • Image field 81
  • Do you have raised, scaly patches on elbows, front or back of knees, or elsewehere on the body?*
  • Do you have any of the following in the affected area? (Select ALL that apply)*
  • How does the affected area feel? (Select ALL that apply)*
  • How bad is your itching?*
  • Please rate the severity of your pain on a pain scale, with 0 being no pain and 10 being the worst pain imaginable.*
  • Have you tried any prescription or over-the-counter medications to treat the affected area?*
  • Did you complete your prescription?*

  • BURNS

  • What burned you?*
  • What chemical substance were you burned by?*
  • Where is the burn located? (Select ALL that apply)*
  • When did your sun exposure occur?*
  • When did you first notice a skin color change or discomfort?*
  • How long were you out in the sun?*
  • Were you wearing sunblock?*
  • How long ago did the burn(s) occur?*
  • Is there clothing or other material stuck to the burn(s)?*
  • What does the skin around the burn(s) look like?*
  • How many burns on your body?*
  • How large is the burn?*
  • Since the burn began, have you experienced any of the following? (Select ALL that apply)*
  • Please rate the severity of your headache on a pain scale, with 0 being no pain and 10 being the worst pain you can imagine.*
  • Are you currently experiencing any of the following? (Select ALL that apply)*
  • Is your skin blistering?*
  • Where are your blisters located? (Select ALL that apply)*
  • Do you have:*
  • When did the blisters form?*
  • Which option best describes your blisters?*
  • Is your burned skin wet or dry?*
  • Please rate the severity of your burn on a pain scale, with 0 being no pain and 10 being the worst pain imaginable. If there is more than one burn, provide the score of the most painful burn.*
  • When are the burn(s) painful?*
  • When your burn is pressed on, does it turn white and then back to red?
  • Which treatments have you tried on your burn so far? (Select ALL that apply)*

  • DIAPER RASH

  • How many days has the rash been present?*

  • Diaper rash occurs on skin covered by the diaper. The specific location can be useful in identifying the cause of the rash. 

  • Where specifically under the diaper area/incontinence brief is the rash located?*
  • Where is the rash located? (Select ALL that apply)*
  • What color is the skin under the diaper/incontinence brief? (Select ALL that apply)*
  • Does the rash include any of the following? (Select ALL that apply)*
  • Does the rash include any of the following? (Select ALL that apply)*
  • How many bumps are present?*
  • How many blisters are present?*
  • What color is the fluid inside the blisters?*
  • Is the rash getting worse?*
  • In the last week, have you had any of the following? (Select ALL that apply)*
  • Have you been treated in a clinic for diaper/incontinence brief rash before?*
  • Have you been treated in a clinic for diaper rash more than once?*
  • Have you ever been treated for eczema?*
  • In the last 2 weeks, have you been exposed to any of the following? (Select ALL that apply)*
  • Have you started using a new product? (Select ALL that apply)*
  • Have you tried any of the following over-the-counter or home remedies? (Select ALL that apply)*
  • Have you been treated with antibiotics within the last 2 weeks?*

  • ECZEMA

  • When did your symptoms start?*
  • Have you been in close contact with anyone that has similar symptoms?*
  • Just before the symptoms started, did you do any of the following? (Select ALL that apply)*
  • Where did you travel?*


  • A rash can refer to many different types of skin conditions. It can cause the skin to change color or become bumpy, blistered, or cracked. Please tell us about the rash:

  • Where is your rash located? (Select ALL that apply)*
  • What is the color of the rash? (Select ALL that apply)*
  • Does your rash have any of the following? (Select ALL that apply)*
  • How many blisters do you have?*
  • What color is the drainage? (Select ALL that apply)*
  • Does your rash have any of the following? (Select ALL that apply)*
  • How does the rash feel? (Select ALL that apply)*
  • Please rate the severity of your pain on a pain scale, with 0 being no pain and 10 being the worst pain imaginable.*
  • Is the rash interfering with your sleep?*
  • Is this the first time you have had this skin condition?*
  • When was the last time you had this skin condition?*
  • Does your current skin condition come and go?*

  • IMPETIGO

  • When did your current symptoms start?*
  • Where are your sores located?*
  • Are the sores only on one side of your face?*
  • Are the sores located together, in a cluster?*
  • Are you experiencing similar sores on other parts of the body other than the mouth area?*
  • How many sores do you currently have?*
  • Do you have any of the following symptoms? (Select ALL that apply)*
  • Did you notice any pain or unusual sensations (such as itching, burning, or tingling) in the location of the sores/rash before it began?*
  • When was the last time you had a rash or outbreak like this?*
  • Does your rash/sores typically go away and come back?*

  • JOCK ITCH

  • When did your symptoms start?*
  • What is the color of the affected area? (Select ALL that apply)*
  • Do you have a rash on the skin that resembles a target or a bruise?*
  • Have you had a recent tick bite?*

  • Do you have raised, scaly patches on elbows, front or back of knees, or elsewhere on body?*
  • Do you have any of the following in the affected area? (Select ALL that apply)*
  • How does the affected area feel? (Select ALL that apply)*
  • How bad is your itching?*
  • Please rate the severity of your pain on a pain scale, with 0 being no pain and 10 being the worse pain imaginable.*
  • Have you tried any prescription or over-the-counter medications to treat the affected area?*
  • Did you complete the prescription?*

  • NAIL CONDITION

  • Which of the following are affected? (Select ALL that apply)*
  • How many are affected?*
  • Is it the big toe?*
  • Which side is the affected area on?*
  • When did your symptoms start?*
  • Did your symptoms start as a result of an injury?*
  • Have you had similar symptoms in the same area before?*
  • Are you experiencing any of the following symptoms? (Select ALL that apply)*
  • Please rate the severity of your pain on a pain scale, with 0 being no pain and 10 being the worse pain imaginable.*
  • Do you experience pain only when pressure is applied to the affected area?*
  • Are you able to walk without limping?*
  • Are you able to comfortably put on shoes?*
  • Are you able to bend your affected finger(s)?*
  • What is the color of the affected area? (Select ALL that apply)*
  • Are you experiencing any of the following symptoms? (Select ALL that apply)*
  • What is the color of the discharge? (Select ALL that apply)*
  • Have you tried any prescription or over-the-counter medications to treat the affected area?*
  • Do you have any of the following conditions? (Select ALL that apply)*

  • SKIN ERUPTION/RASH

  • When did your symptoms start?*
  • Have you been in close contact with anyone that has similar symptoms?*
  • Just before the symptoms started, did you do any of the following? (Select ALL that apply)*
  • Where did you travel?*
  • Where is the skin condition located? (Select ALL that apply)*

  • Although a shingles rash can appear on any body part, it is usually limited to one side of the body.

  • Where is your rash located?*
  • What is the color of the affected area?*
  • Do you have a rash on the skin that resembles a target or a bruise?*
  • Have you had a recent tick bite?*

  • Do you have raised, scaly patches on elbows, front or back of knees, or elsewhere on body?*
  • Do you have any of the following in the affected area? (Select ALL that apply)*
  • How many blisters do you have?*
  • What color is the drainage?*
  • Do you have any of the following in the affected area?*
  • Do you currently have any of the following?*
  • How does the affected area feel?*
  • Do you have pitting edema (this is when a swollen part of your body has a dimple, or pit after you press it for a few seconds)?*
  • How bad is your itching?*
  • Please rate the severity of your pain on a pain scale, with 0 being no pain and 10 being the worst pain imaginable.*
  • Are the symptoms interfering with your sleep?*
  • Did you notice any pain or unusual sensations (such as itching, burning, or tingling) in the location of the rash before it began?*
  • Have you ever had any of the following? (Select ALL that apply)*
  • Have you received the chickenpox vaccines?*
  • Did you receive the shingles vaccine?*
  • Since your skin condition started, has it changed in any of the following ways? (Select ALL that apply)*
  • Is this the first time you had this skin condition?*
  • When was the last time you had this skin condition?*
  • Does your current skin condition come and go?*
  • Were you bitten or stung by an insect?*
  • What type of insect bit or stung you?*
  • Did the symptoms begin immediately after you were bitten or stung?*

  • ROSACEA

  • What is the history of your condition?*
  • When did you start having problems with this condition?*
  • How long ago was your last in-person visit with a provider for this condition?*
  • What part of your body is affected? (Select ALL that apply)*
  • Which part of your face is affected? (Select ALL that apply)*


  • First, we're going to ask about current symptoms. Then, we will ask about symptoms you have experienced in the past. 

  • Do you currently have any of the following symptoms? (Select ALL that apply)*
  • How many cysts do you currently have?*
  • Do you currently have any of the following on the face? (Select ALL that apply)*
  • Do you currently have any of the following on the face? (Select ALL that apply)*
  • Do you currently have any of the following? (Select ALL that apply)*


  • A keloid is a smooth, raised, shiny scar that is usually larger than the original injury and darker than the surrounding skin.

  • Do you have keloids on the face?*
  • Which of the following symptoms have you had in the past? (Select ALL that apply)*

  • INSECT BITE OR STING

  • This visit is intended for patients who have been bitten or stung by an insect. It is not intended for other animal bites (such as dog, cat, human, or reptile bites).

  • Have you been bitten or stung by an insect?*
  • Which type of insect bit or stung you?*
  • Do you have any of the following symptoms of a severe reaction? (Select ALL that apply)*
  • How long ago were you bitten or stung?*
  • Where did the insect bite or sting you? (Select ALL that apply)*
  • When did your current symptoms begin?*
  • Have you been bitten by a tick?*
  • Is the tick still attached?*
  • Did you or someone else see the tick?*

  •  

     

     

     

     

    Deer ticks go through 3 life stages, larvae, nymph, and adult. Most people with deer tick bites get bitten by a nymph or an adule female. A nymph is 1-2 mm long (C), about the size of a poppy seed. An adult female deer tick is 3-5 mm long (A), about the size of a sesame seed. Please refer to the image above to see how deer ticks in their different stages compare in size: adult female (A), adult male (B), nymph (C), larva (D). 

  • Did the tick look like a deer tick?*
  • How long was the tick attached to your skin?*
  • When did you remove the tick or when did it come off?*

  • Do you have a rash on the skin that resembles a target?*
  • Has the rash expanded or become larger since you were bitten by the tick?*
  • At the time you were bitten by the tick, were you doing any of the following? (Select ALL that apply)*
  • What is the color of the affected area? (Select ALL that apply)*
  • Are you experiencing any of the following around the suspected bite? (Select ALL that apply)*
  • Do you have pitting edema? (This is when part of your body leaves a dimple or pit after you press it for a few seconds)*
  • Please rate the severity of your pain on a pain scale, with 0 being no pain and 10 being the worst pain imaginable.*
  • Do you have a fluid-filled area, larger than a penny, developed under the skin (not a blister) that moves around when pushed into?*
  • Do you have any of the following in the bite area? (Select ALL that apply)*
  • Is there any pus (thick yellowish, whitish, or greenish fluid) draining from the bite?*
  • What is the approximate size of the area filled with pus?*
  • Since the time of the tick bite, have you had any of the following symptoms? (Select ALL that apply)*
  • Please rate the severity of your headache on a pain scale, with 0 being no pain and 10 being the worst pain imaginable.*
  • Since the bite or sting, have you noticed any skin changes that are not located around or near the bite or sting?*
  • Did you get the bite or sting traveling outside of the United States?*
  • Have you experienced any side effects in the past while taking the antibiotic doxycycline such as an upset stomach, vomiting, or diarrhea?*

  • ACNE

  • What is the history of your condition?*
  • When did you start having problems with this condition?*
  • How long ago were you diagnosed with acne?*
  • How long ago was your last in-person visit with a provider for this condition?*
  • What part of your body is affected?*
  • What part of your face is affected? (Select ALL that apply)*

  • First, we're going to ask about current symptoms, Then, we will ask about symptoms experienced in the past. 

  • Do you currently have any of the following? (Select ALL that apply)*
  • How many cysts do you currently have?*
  • Do you currently have any of the following on the face? (Select ALL that apply)*
  • Do you currently have either of the following? (Select ALL that apply)*
  • Do you have keloids on the face? (A keloid is a smooth, raised, shiny scar that is usually larger than the original injury and darker than the surrounding skin)*
  • Which of the following symptoms has you had in the past? (Select ALL that apply)*

  • Acne can be a symptom of a medical condition in which a female develops characteristics associated with male hormones. When acnes is caused by this, it might not respond to the typical acne treatment. 

  • Does acne regularly worsen at the same points in your menstrual cycle?*
  • Do you have any of the following symptoms? (Select ALL that apply)*

  • The hormones in some birth control pills can help control acne triggered by hormonal changes. 

  • Are you currently taking a birth control pill?*
  • Would you take a birth control pill to treat acne if it was prescribed?*
  • Is the birth control pill prescribed to control acne?*
  • What birth control pill are you taking?*
  • Have you used any over-the-counter acne treatments?*
  • Have the over-the-counter acne treatments been effective?*
  • What acne treatments have been effective in the past? (Select ALL that apply)*
  • Have you tried anything for symptoms relief?*
  • What have you tried to relieve the symptoms? (Select ALL that apply)*
  • Was the over-the-counter topical ointment or cream (such as hydrocortisone) helpful?*
  • Was the over-the-counter oral medication (such as Ibuprofen, Tylenol, or Benadryl) helpful?*
  • Was the prescription topical ointment or cream (such as Triamcinolone) helpful?*
  • Are you able to upload a picture of the affected area? (You may be required to upload a picture before the visit can be completed)*
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  • MEDICAL HISTORY

  • Have you had a tetanus shot recently (within the last 10 years)?*
  • Do you feel feverish?*
  • Have you taken your temperature in the last 24 hours or are you able to take your temperature now?*
  • Treatment for various skin conditions may vary based on different skin tones. Please select your skin tone:*
  • What is your skin type?*
  • Do you have sensitive skin?*
  • Do you have a history of any of the following conditions? (Select ALL that apply)*
  • Does anyone in your immediate family (biological mother, father, sister, brother, child) have a history of any of the following conditions? (Select ALL that apply)*
  • Do you have any of the following conditions? (Select ALL that apply)*
  • Do you have any of the following conditions? (Select ALL that apply)*
  • Have you had a hemoglobin A1C taken in the last 5 months?*
  • Please select the HbgA1C range that accurately reflects your result:*
  • Do any of the following immunosuppressive treatments or conditions apply to you? (Select ALL that apply)

  • Depending on your symptoms, an antibiotic may be prescribed which can sometimes cause yeast infections. 

  • Do you typically get a vaginal yeast infection when taking antibiotics?*
  • What has successfully traded your yeast infections in the past? (Select ALL that apply)*
  • Do you have any medication allergies?*
  • Are you currently taking any medications?*
  • Are you pregnant?*
  • Are you breastfeeding?*

  • PHARMACY INFORMATION

    Please choose where you would like your prescription sent
  • Would you like to add any additional information or questions for the provider to see?*

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