Dermatology Medical History



Patient: ___________________________________________________________ Date of Birth:______/_____/_____ Today’s Date:_____/_____/_____

Are you allergic to any medications? οYes ο No If yes, please list:___________________________________________________________________

Primary Care Physician: ______________________________________________________ Is this a referral? οYes ο No

Have you ever had dental anesthesia (Novacaine)? οYes ο No Any bad Reaction? οYes οNo

List all medications you are currently taking (including prescriptions, over-the-counter meds, vitamins, and herbals):

1._____________________________2._____________________________3._____________________________4._____________________________

5._____________________________6._____________________________7._____________________________8._____________________________

9. ____________________________10.____________________________11.____________________________12._____________________________

Do you have now, or have you ever had diseases or conditions of: (Please check YES or NO)

YES NO YES NO

Bronchitis ( ( Diabetes ( (

Emphysema ( ( Excessive thirst/hunger ( (

Asthma ( ( Amputation ( (

Chronic Cough ( ( Thyroid ( (

Morning Cough ( ( Kidney ( (

Shortness of Breath ( ( Dialysis ( (

Wheezing ( ( Bladder ( (

High Blood Pressure ( ( Frequency/burning ( (

Chest Pain ( ( Yeast infection when taking antibiotics ( (

Heart Attack ( ( Arthritis/Joint Deformity ( (

Heart Murmur ( ( Arthralgia ( (

Irregular Heartbeat ( ( Limited motion ( (

Phlebitis ( ( Artificial Joint ( (

Inflammation of vein ( ( Gastrointestinal ( (

Blood Clots ( ( Nausea, vomiting, diarrhea

Convulsions, Epilepsy, when taking antibiotics ( (

Fainting or seizures ( ( Stomach absorptive disorder ( (

Pacemaker ( ( Defibrillator ( (

List any other diseases or conditions: ____________________________________________________________________________________________

List surgical procedures you have had in the last 6 months: ___________________________________________________________________________

Skin: Have you ever had skin cancer? οYes  οNo If YES, what type? _______________________________________________________

____________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________________

Do you have problems healing? οYes  οNo Do you develop keloids (scars) after surgery? οYes  ο No

Do you bleed easily? οYes  ο No

Has anyone in your family had skin cancer?  οYes  οNo If YES, what type? ___________________________________________________

Do you have a history of any specific skin diseases? οYes  οNo If YES, what type? __________________________________________________

Do you develop skin rashes in reaction to: οMedications οFood οEnvironment οBandages οTopical οNeosporin οOther: _____________________

Social History:

Do you drink alcohol? οYes ο No If YES, number of drinks per day _________ Do you smoke? οYes οNo If YES, how much: _______________

Have you had or have you been exposed to HIV (AIDS) or Hepatitis? οYes οNo If YES, explain: _______________________________________

(Women) Are you pregnant or trying to become pregnant?  οYes  οNo If YES, due date: _____/_____/_____

Occupation: _____________________________________________ Hobbies? ___________________________________________________________

Completed by: οPatient οMed. Asst. __________ _______________________________________________________Date: _____/_____/_____

M.A. Init. Signed by Patient

_______________________________________________________Date: _____/_____/_____

Reviewed by

____/____/____ _____ ____/____/____ _____ ____/____/____ _____ ____/____/____ _____ ____/____/____ _____ Updated Init. Updated Init. Updated Init. Updated Init. Updated Init.

____/____/____ _____ ____/____/____ _____ ____/____/____ _____ ____/____/____ _____ ____/____/____ _____ Updated Init. Updated Init. Updated Init. Updated Init. Updated Init.

____/____/____ _____ ____/____/____ _____ ____/____/____ _____ ____/____/____ _____ ____/____/____ _____ Updated Init. Updated Init. Updated Init. Updated Init. Updated Init.

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download