Dermatology Center of Washington Township



Dermatology Center of Washington Township, PCJonathan Winter MD ? Elana Segal MD ? Joshua Freedman MD ? Gregory Persichetti DO ? Amy Krachman DO ? Amy Morris PA-C ? Marissa Ionno PA-CMedical HistoryPatient: ___________________________________________ Date of Birth: ________/_______/_________ Today’s Date: _______/_______/________Reason for today’s visit: _________________________________________________________________________________________________________Are you allergic to any medications? □ YES □ NO If yes, please specify: _______________________________________________________________ Have you ever had dental anesthesia (Novacaine)? □ YES □ NO Any bad reaction? □ YES □ NO If yes, explain: ____________________________Current Medications (including prescriptions, over-the-counter meds, vitamins, and herbal supplements): ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Do you have now, or have you ever had any of the following diseases, conditions or problems with: (Please check appropriate box) LUNGS: YES NO OTHER SYSTEMIC: YES NOBronchitis□□ Diabetes □ □ Emphysema□□ Excessive thirst/Hunger □ □Asthma□□ Amputation(s) □ □Chronic Cough□□ Thyroid □ □Morning Cough□□ Kidney □ □Shortness of Breath□□ Dialysis □ □Wheezing□□ Bladder □ □ Frequent/Painful Urination □ □CARDIOVASCULAR: Gastrointestinal □ □High Blood Pressure□□ Stomach Absorptive Disorder □ □Chest Pain□□ Nausea, Vomiting, Diarrhea with antibiotics □ □Heart Attack□□ Yeast Infection when taking antibiotics □ □Stroke□□ Arthritis/Arthralgia □ □Heart Murmur□□ Joint Deformity □ □Irregular Heartbeat □□ Limited Motion □ □Mitral Valve Prolapse□□ Artificial Joint □ □Pacemaker□□ Convulsions, Epilepsy, Seizures, □ □Phlebitis□□ Fainting □ □Blood Clots□□ List Any Other Diseases or Conditions: _____________________________________________ Surgical Procedures in the last 6 months: ____________________________________________ SKIN: Have YOU ever had skin cancer?□□ If YES, □ Basal Cell □ Squamous Cell □ Melanoma □ Other_______________ □ Not SureFamily member with skin cancer?□□ If YES, Who: __________________________Type: ___________________________ □ Not SureDo you bleed easily?□□Do you develop keloids (scars)?□□Do you have problems healing?□□Do you have a history of any specific skin diseases? □ YES, _________________________________________________ □ NODo you develop skin rashes in reaction to: □ Food □ Environment □ Medications □ Bandages □ Neosporin □ Topicals □ Other SOCIAL HISTORY: YES NOAre you a smoker?□□ □ Current □ Former □ Never If YES, how much: __________per day__________ week Do you drink alcohol?□□ □ Socially □ Daily □ Never If YES, how much: __________per day__________ weekIV drug user □□ □ Current □ Former □ Never If YES, specify:____________________________________ Have you ever been diagnosed with or exposed to HEPATITIS A, B or C, HIV or AIDS? □ YES □ NO If YES, specify:__________________________ What is your occupation: __________________________________ Hobbies: ___________________________________________________________FEMALE PATIENTS ONLY: Currently Pregnant? □YES □NO Trying to Conceive? □YES □NO Breastfeeding? □YES □NO Using Oral Contraceptives? □YES □NO If YES, Completed by: □ Patient ________ __________________________________ ______/_______/_________ ______/_______/_________ _______ Initials Signature of Patient Date UpdatedInitials □ Med. Asst.________ __________________________________ ______/_______/__________ ______/_______/_________ _______ NurseInitials Reviewed By Date UpdatedInitialsCultural Competency The state of New Jersey mandates that every physician documents any barrier to care, including cultural and linguistic needs, in the medical record. Factors affecting care are visual or auditory factors, which may impede your ability to comprehend medical discussion and language, cultural and/or religious customs, which may impact the provider’s ability to provide medical care. Addressing these needs will improve patient satisfaction and also decrease health care disparities. PATIENT NAME: DATE OF BIRTH:Do you have any impairment? (Please circle any that apply):VisualHearingSpeechLearningPhysical Language/Cultural barrierNoneWhat language do you speak, read and write?Do you have any religious or cultural customs that the doctor should know about? (If choose yes, please explain):Yes, Please explain NoADVANCE DIRECTIVES: FOR ALL PATIENTS 18 YEARS AND OLDER: Advanced Directive is a federal and state mandated Self-Determination Act enacted in 1990. This allows you to provide specific instruction and direction regarding your own medical care wishes if you become incapacitated. The patient-physician relationship provides a direct opportunity for you to discuss these types of decisions. Do you have a “Living Will” or Advance Directive? (Please Circle)YesNo Signature Date ................
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