Family Dermatology – Healthy Skin for the Whole Family
Medical History FormFamily Dermatology5603 Duraleigh Rd, Suite 111, Raleigh, NC 27612860 Perry Road,Apex, NC 27502919-791-0840Chart # (the office will write this in): ____________________________Name: _______________________________ Gender: ___________ Age: ______________Patient race: __________________________Ethnicity: _________________________________________________Preferred language: _____________________________________________________________________________________How did you hear about us (who referred you?): ________________________________________________________Please list your primary care physician: _________________________________________________________________Please list any other providers you would like your office notes sent to: __________________________________________________________________________________________________________________________________Please provide your e-mail for appointment reminders: _____________________________________________________Reason(s) for today’s visit:1. ____________________________________________________________________________2. ____________________________________________________________________________Have you had an atypical (dysplastic) mole biopsied? ______________________________________________________Have you had a basal or squamous cell carcinoma? ________________________________________________________Have you had a melanoma? ___________________________________________________________________________Has your father, mother, brother, sister, son or daughter had a melanoma? ______________________________________Do you have a history of any other cancer? ______________________________________________________________Do you smoke or use other tobacco? __Current smoker __Former __NeverDo you now or have you ever had (please check what applies):__Artificial heart valve__Diabetes__Lupus__Artificial joint (knee, etc.)__Hypertension__Arthritis__Pacemaker__Hepatitis B __Thyroid disease__Defibrillator__Hepatitis C__HIV or AIDS__Radiation treatment (if so list body parts): ______________________________Any other disease or condition we should know about? _____________________________________________________Please provide a phone number where we can reach you during the day: ______________________________________May we speak with your family members regarding your problems and test results? _____________________________Do you have any cosmetic concerns? __________________________________________________________________Would you like to receive emails about our cosmetic specials? ___ Yes ___ NoMedicare Patients WomenName and # of health care proxy if you have one: ___________________________ Are you pregnant? _____Do you have a living will? __________________________ Breastfeeding? ____Which best reflects your wishes: ___Do not resuscitate __Do not intubate __Do it all! Planning pregnancy?____Have you received the pneumonia vaccine (Pneumovax)? ________ Please sign below acknowledging you have reviewed our privacy and financial policies (copies are located at the check in desk).___________________________________________________ ___________________________ Signature DateName: ________________________________________Date of Birth: ___________________________________Are you allergic to latex, lidocaine, or any other medications? _______________________________________________List drug(s) and reaction(s):________________________________________________________________________________________________________________________________________________Are you on any blood thinners? ________________________________________________________________________List all medications, over the counter supplements and vitamins that you take daily or as needed. Please include dosage and frequency.NameDoseFrequencyPharmacy InformationName of pharmacy: _____________________________________Street it is on: _____________________________________City it is in: _____________________________________
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