<p> Dermatology Medical History</p><p>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):</p><p>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)</p><p>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? ______</p><p>______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: ______</p><p>(Women) Are you pregnant or trying to become pregnant? Yes No If YES, due date: _____/_____/_____ Occupation: ______Hobbies? ______</p><p>Completed by: Patient Med. Asst. ______Date: _____/_____/_____ M.A. Init. Signed by Patient</p><p>______Date: _____/_____/_____ Reviewed by ____/____/______/____/______/____/______/____/______/____/______Updated Init. Updated Init. Updated Init. Updated Init. Updated Init. </p><p>____/____/______/____/______/____/______/____/______/____/______Updated Init. Updated Init. Updated Init. Updated Init. Updated Init. Dermatology Medical History</p><p>____/____/______/____/______/____/______/____/______/____/______Updated Init. Updated Init. Updated Init. Updated Init. Updated Init. </p>