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: ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______

-----------------------

Label

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

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

Google Online Preview   Download