Dermatology Medical History
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Dermatology Medical History
Patient: ______Date of Birth:______/_____/_____ Today’s Date:_____/_____/_____ Are you allergic to any medications? Yes No If yes, please list:______Primary Care Physician: ______Is this a referral? Yes No Have you ever had dental anesthesia (Novacaine)? Yes No Any bad Reaction? Yes No 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? Yes No If YES, what type? ______
______Do you have problems healing? Yes No Do you develop keloids (scars) after surgery? Yes No Do you bleed easily? Yes No Has anyone in your family had skin cancer? Yes No If YES, what type? ______Do you have a history of any specific skin diseases? Yes No If YES, what type? ______Do you develop skin rashes in reaction to: Medications Food Environment Bandages Topical Neosporin Other: ______Social History: Do you drink alcohol? Yes No If YES, number of drinks per day ______Do you smoke? Yes No If YES, how much: ______Have you had or have you been exposed to HIV (AIDS) or Hepatitis? Yes No If YES, explain: ______
(Women) Are you pregnant or trying to become pregnant? Yes No If YES, due date: _____/_____/_____ Occupation: ______Hobbies? ______
Completed by: Patient Med. 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. Dermatology Medical History
____/____/______/____/______/____/______/____/______/____/______Updated Init. Updated Init. Updated Init. Updated Init. Updated Init.