MHL, M
Mark H. Lowitt, MD, LLC
DERMATOLOGY MEDICAL HISTORY
Are you allergic to any medications? ρ Yes ρNo If yes, list below:
1.____________________________ 2. ______________________________
Have you ever had a bad/allergic reaction to: (Circle) Novocaine / Lidocaine / Betadine / Iodine / adhesives ?
List all medications you are currently taking (including prescriptions, over-the-counter meds, Vitamins, and herbals):
1.___________________________ 3._____________________________ 5. __________________________
2. ___________________________ 4. _____________________________ 6. __________________________
Do you have now, or have ever you had diseases or conditions of: (Please check YES or NO):
| |YES |NO | |Other Systemic: |YES |NO |
|Bronchitis/Emphysema |ρ |ρ | |Diabetes |ρ |ρ |
|Asthma |ρ |ρ | |Thyroid condition |ρ |ρ |
|Shortness of Breath |ρ |ρ | |Kidney disease |ρ |ρ |
|High blood pressure |ρ |ρ | |Dialysis |ρ |ρ |
|Heart attack / angina |ρ |ρ | |Bladder problem |ρ |ρ |
|Chest pain |ρ |ρ | |Gastrointestinal problems |ρ |ρ |
|Heart murmur |ρ |ρ | |Nausea/Vomiting from |ρ |ρ |
|Irregular heartbeat |ρ |ρ | | Oral antibiotics |ρ |ρ |
|Phlebitis / Blood clots |ρ |ρ | |Yeast infection from |ρ |ρ |
|PACEMAKER |ρ |ρ | | Oral antibiotics |ρ |ρ |
|Fainting |ρ |ρ | |Arthritis |ρ |ρ |
|Allergies / Hay fever |ρ |ρ | |ARTIFICIAL JOINT |ρ |ρ |
|Ear/nose/sinus/throat problems |ρ |ρ | |Convulsions / epilepsy |ρ |ρ |
List any other diseases or conditions: ______________________________________________________________
List surgical procedures you have had: _____________________________________________________________
| |YES |NO |DETAILS |
|Have you ever had skin cancer? |ρ |ρ | |
|Has anyone in your family had skin cancer? |ρ |ρ | |
|Has anyone in your family had Melanoma? |ρ |ρ | |
|Do you have a history of any other skin diseases? |ρ |ρ | |
|Do you have problems with healing? |ρ |ρ | |
|Do you develop keloid scars after surgery? |ρ |ρ | |
|Do you bleed easily? |ρ |ρ | |
Do you drink alcohol? ρ YES ρ NO If YES___________ drinks per day
Do you use IV drugs? ρ YES ρ NO If YES, what? _____________________ How often?
Do you smoke? ρ YES ρ NO If YES, how much: ______________________________________
Have you had or have you been exposed to HIV (AIDS)? ρ YES ρ NO
Are you: Single ρ Married ρ Separated/Divorced ρ Widowed ρ GLBT ρ
(Women) Are you pregnant? ρ YES ρ NO Due Date: ___/___/___
What is your occupation? ________________________________ Hobbies? _____________________________
_______________________ ____/____/_____
PATIENT SIGNATURE Date
_______________________ ____/____/_____
Reviewed by Date
Reviewed: ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______
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Label
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