Aesthetic and Clinical Dermatology Associates of Hinsdale
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New Patient Medical History Form
Name: ________________________________________________ Age: ________ DOB: _______/_______/_______
Referring Physician _____________________________ Primary Care Physician: ________________________________
Reason for today’s visit: ______________________________________________________________________________
Is your current skin condition (Please circle): Bleeding Itching Painful Growing Changing
Duration of skin condition: ___________________ Do you routinely take aspirin (Please Circle)? Yes No
When exposed to the sun do you (Please Circle): Tan Tan & Burn Burn
For females: Having periods? Yes No Are periods regular? Yes No Are you pregnant? Yes No
Personal Past Medical History or Current Disease (s) (Please Circle if Yes):
Skin Cancer Y N HIV/AIDS Y N
Actinic Keratosis Y N Hepatitis C/Liver Disease Y N
Melanoma Y N Thyroid Disorders Y N
Cancer (other than skin cancer) Y N Diabetes Y N
Psoriasis Y N Kidney Disease Y N
Childhood eczema Y N High Blood Pressure Y N
Seasonal allergies or hay fever Y N Heart Attack or Stroke Y N
Asthma Y N Artificial Heart Valve Y N
Keloid Y N Pacemaker/Defibrillator Y N
Anesthetic Complications Y N Organ/Bone Marrow transplant Y N
Autoimmune Disease Y N Artificial Joint within 6 months Y N
If you answered YES to any of the above, please explain: _____________________________________________
___________________________________________________________________________________________
Other major medical illnesses/surgeries: __________________________________________________________
Family History: If any blood relative has any condition listed below, check and specify which blood relative.
Allergies/ Hay fever ( ) ___________ Severe Acne ( ) __________ Other Cancer ( ) __________
Childhood Eczema ( ) ___________ Psoriasis ( ) __________ Heart Disease ( ) __________
Asthma ( ) ___________ Diabetes ( ) __________ High Blood Pressure ( ) __________
Hives ( ) ___________ Skin Cancer ( ) __________ Autoimmune Disease ( ) __________
Rosacea ( ) ___________ Melanoma ( ) __________
Social History:
Tobacco Use: Current Former Never Relationship Status: Single Married Divorced Widow Other
Alcohol Use: Current Everyday Current Someday Former Never
Allergies: Do you have any known drug allergies: Yes No If yes, please list which drugs.
___________________________ ________________________________ _____________________________
___________________________ ________________________________ _____________________________
Are you allergic to latex: Yes No
Current Medications (Prescribed and Non-Prescribed) please list:
____________________________ ____________________________ ____________________________
____________________________ ____________________________ ____________________________
___________________________________________ ____________________________
Patient/Guardian Signature Date
___________________________________________ ____________________________
Reviewed By Date
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