Messengerdermatology.com



Messenger Dermatology - CompassName: FORMTEXT ?????Date: FORMTEXT ?????CURRENT MEDICAL HISTORYList all Medications you are currently taking. Include prescription and over-the-counter medications: FORMTEXT ?????List any known reactions, sensitivities or allergies to food, flowers, plants, weeds or rubber: FORMTEXT ?????List any medications you may be allergic or sensitive to: FORMTEXT ?????Do you use: FORMCHECKBOX Tobacco FORMCHECKBOX Caffeine FORMCHECKBOX AlcoholIf applicable, are you or could you be pregnant?: FORMCHECKBOX Yes No Are you at risk for HIV?: FORMCHECKBOX Yes FORMCHECKBOX NoDo you require prophylactic antibiotics before a surgical procedure?: FORMCHECKBOX Yes FORMCHECKBOX No (heart murmur or prosthetic joints, etc.)PAST MEDICAL HISTORYList any previous skin conditions you have had: FORMTEXT ?????Have you ever had a history of allergies, eczema, hayfever, asthma, hives, migraines or nasal polyps?: FORMTEXT ?????Have you ever had any of the following? Please check all that apply: FORMCHECKBOX Anemia FORMCHECKBOX Arthritis FORMCHECKBOX Liver Problems FORMCHECKBOX Bleeding problems FORMCHECKBOX Tuberculosis FORMCHECKBOX Kidney Problems FORMCHECKBOX Blood Clots FORMCHECKBOX Thyroid Problems FORMCHECKBOX Blood Transfusion FORMCHECKBOX Diabetes FORMCHECKBOX Heart Problems FORMCHECKBOX Stomach Ulcers FORMCHECKBOX Glaucoma FORMCHECKBOX Lung Problems FORMCHECKBOX Intestinal Disorders FORMCHECKBOX Nervous/Mental Disorder FORMCHECKBOX High Blood Pressure FORMCHECKBOX Back Problems FORMCHECKBOX Cancer (other than skin) FORMCHECKBOX Hepatitis/Jaundice FORMCHECKBOX Artificial Joints FORMCHECKBOX Artificial Heart/Valves FORMCHECKBOX PacemakerDo you have any other medical problems not listed above?: FORMTEXT ?????FAMILY MEDICAL HISTORYIs there any family history of heart disease, stroke or cancer (including melanoma)?: FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, please explain: FORMTEXT ?????Please verify information, initial and date below:Initials: ________ Date: _______ Initials: ________ Date: _______ Initials: ________ Date: _______Initials: ________ Date: _______ Initials: ________ Date: _______ Initials: ________ Date: _______ ................
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