<p> Label Mark H. Lowitt, MD, LLC DERMATOLOGY MEDICAL HISTORY Are you allergic to any medications?  Yes No 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   Diabetes   Asthma   Thyroid condition   Shortness of Breath   Kidney disease   High blood pressure   Dialysis   Heart attack / angina   Bladder problem   Chest pain   Gastrointestinal problems   Heart murmur   Nausea/Vomiting from   Irregular heartbeat   Oral antibiotics   Phlebitis / Blood clots   Yeast infection from   PACEMAKER   Oral antibiotics   Fainting   Arthritis   Allergies / Hay fever   ARTIFICIAL JOINT   Ear/nose/sinus/throat problems   Convulsions / epilepsy  </p><p>List any other diseases or conditions: ______</p><p>List surgical procedures you have had: ______YES NO DETAILS Have you ever had skin cancer?   Has anyone in your family had skin cancer?   Has anyone in your family had Melanoma?   Do you have a history of any other skin diseases?   Do you have problems with healing?   Do you develop keloid scars after surgery?   Do you bleed easily?  </p><p>Do you drink alcohol?  YES  NO If YES______drinks per day Do you use IV drugs?  YES  NO If YES, what? ______How often? Do you smoke?  YES  NO If YES, how much: ______Have you had or have you been exposed to HIV (AIDS)?  YES  NO Are you: Single  Married  Separated/Divorced  Widowed  GLBT  (Women) Are you pregnant?  YES  NO Due Date: ___/___/___</p><p>What is your occupation? ______Hobbies? ______</p><p>______/____/_____ PATIENT SIGNATURE Date</p><p>______/____/_____  Reviewed by Date Reviewed: ______</p>