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: _____________________________________________

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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:

____________________________ ____________________________ ____________________________

____________________________ ____________________________ ____________________________

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Patient/Guardian Signature Date

___________________________________________ ____________________________

Reviewed By Date

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