Mitchell Dermatology Medical Information
Patient Name
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First Name
Last Name
Age
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Occupation
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Reason for your visit today
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Marital Status
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Plese Select
Married
Single
Divorced
Separated
Widowed
Pharmacy Name
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Pharmacy Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Pharmacy Location
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Do you take current medications
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Yes
No
If "Yes" List current medications
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Do you have Current Allergies to medication?
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Yes
No
If "Yes" List Current Allergies
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Do you occasionally use
Motrin/other NSAIDS
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Yes
No
Aspirin/ Blood Thinners
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Yes
No
Birth Control
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Yes
No
Itching Pills
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Yes
No
Allergy Pills
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Yes
No
Social History
Pregnant
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Yes
No
Nursing
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Yes
No
Do you smoke cigarettes
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Yes
No
Have you ever smoked
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Yes
No
Do you use alcohol
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Yes
No
How Frequently
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Do you have Major medical problems?
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Yes
No
If "Yes" List Major medical problems
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Do you have Recent Surgery or Illness?
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Yes
No
List Recent Surgery / Illness
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Do you have any of these conditions (Select all that apply)
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Asthma
Diabetes
High Blood Pressure
Depression
Hypothyroid
Bleeding Tendencies
AIDS / HIV
Pacemaker
Artificial Valve/ Joint
Hepatitis
Lung Disease
Acid Reflux
Low Blood Pressure
Anxiety
Hyperthyroid
Migraines
Stomach Ulcers
Chrohn’s Disease
Irritable bowel Syndrome
Seasonal Allergies
None
Do you have any other current skin concerns: (i.e sun spots, skin tags, Wrinkles)
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Yes
No
If Yes please explain:
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Skin Cancer History
Have you ever had a mole removed?
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Yes
No
If Yes diagnosis
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Have you ever had skin cancer?
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Yes
No
Diagnosis
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If yes, type
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Basal Cell Carcinoma
Squamous Cell Carcinoma
Melanoma
None
Do you use a sunscreen?
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Yes
No
Type?
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(currently use)
SPF
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Do you use a tanning bed
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Yes
No
Do you lay out in the sun
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Yes
No
Have you ever sunburned
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Yes
No
Do you have any of the following
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Abnormal Moles
Dry Skin
Eczema
Itchy Skin
Rash
Scars
Cold sores
Acne
Sensitive skin
Hives
Psoriasis
Rosacea
Sores that won’t heal
Redness
None
Do you have an interest in the following
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Botox
Dysport
Restylane
Microneedling
Juvederm
Voluma
Radiesse
Coolsculpting
Chemical Peels
Anti-aging treatments
None
Other
Family History
Has any family member had skin cancer or melanoma?
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Yes
No
Who?
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Has any family member had eczema or psoriasis?
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Yes
No
Who?
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Please list all skin care products you
*
Patient Signature
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Patient Name
*
First Name
Last Name
Date
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Month
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Day
Year
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