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.
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