Med History Form - NC ENGLISH

Today's Date *

Date

Patient Name *

First Name Last Name

Date of Birth *

Date

Email

example@example.com

Name of Primary Care Doctor (enter "None" if you do not have a primary care doctor): *

Please list any other referring provider you would like us to send your visit notes to:

Ethnicity

Gender *

Male Female

List ALL skin issues that you would like to discuss with the doctor (please be specific). *

List ALL skin medications and over the counter products you are currently using / have used for the issues you stated above.

Have you ever had a mole(s) removed? *

No Yes, and all were benign Yes, and at least one was atypical /abnormal

Have you ever had skin cancer? *

No Yes

If yes, please indicate 1) the type of skin cancer (BCC, SCC, Melanoma), 2) where on your body, 3) what year and how was it treated, and 4) the name/contact of your treating physician.

Do you have a history of any specific skin disease? *

No Yes

If yes, please explain.

Do you have any changing moles? *

No Yes

If yes, where?

Are you allergic to any medications? *

No Yes Unknown

If yes, please list them here.

Please list any medications you are currently taking, including over-the-counter, vitamins, and herbs.

List any surgical procedures/hospitalizations you have had and the years.

If you have had any organ transplants, please describe.

Please check the box(es) for any diseases or conditions you currently have or have had in the past. *

If you checked any diseases/conditions above, please explain here. If you checked Tuberculosis, please indicate if treated, latent, or active.

List any other conditions you currently have or have had.

Please carefully review this symptom list:

General: weight change, change in energy, change in strength or exercise
tolerance

Head: headaches, vertigo, head injury

Eyes: change in vision, seeing double, tearing, partial vision loss, eye pain Ears:
change in hearing, ringing, bleeding, vertigo/dizziness Nose: bleeding noses, running nose, obstruction, discharge

Mouth: dental difficulties, gingival bleeding, use of dentures

Neck: stiffness, pain, tenderness, masses

Breast: lumps, tenderness, swelling, nipple discharge

Chest: shortness of breath, wheezing, coughing up blood, chronic coughing

Heart: chest pains, palpitations, syncope

Abdomen: change in appetite, trouble swallowing, abdominal pains, bowel habit
changes, blood in your stool

GU: urinary urgency, pain with urinating, change in nature of urine

Women Gyn: change in menses, pain with menses, vaginal discharge, pelvic pain

Musculoskeletal: pain in muscles or joints, limitation of range of motion, numbness

Neurologic: weakness, tremor, seizures, changes in mentation, lack of coordination

Psychiatric: depressive symptoms, changes in sleep habits, changes in thought content

Other: excessive sweating

Are you experiencing any of the symptoms listed above? *

No Yes

If yes, please indicate symptoms here.

Occupation (past or present):

Are you or have you ever been a smoker? *

No Yes, quit Yes, current

If a current smoker, how much do you smoke per day?

Do you have a past or present issue with alcohol/drug abuse? *

No Yes

If yes, please explain.

Hobbies

Females, are you currently pregnant, or is there a chance you may be pregnant? *

No Yes

Females, are you currently breastfeeding? *

No Yes

Please check any of the below diseases that run in your family.

When you are exposed to sun, do you: *

Tan only Tan and burn Burn only

Have you ever developed a keloid (large scar) after surgery? *

No Yes

Do you wear sunscreen? *

No, never Yes, sometimes when I'm outside Yes, always when I'm outside Yes, daily

Have you ever used a tanning bed? *

No, never Yes, in the past Yes, currently

Preferred Pharmacy *

If you selected Other above, please list your pharmacy here.

Would you prefer a hand-written Rx?

No Yes

San Diego Family Dermatology Medical History Form