Dermatology Medical History
Name
*
First Name
Middle Name
Last Name
Reason for today's visit
Are you allergic to any medications ?
*
Yes
No
If yes, list
*
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)
Do you have now, or have you ever had diseases or conditions of: (Please check YES or NO)
Lungs
Bronchitis
Yes
No
Emphysema
Yes
No
Asthma
Yes
No
Chronic Cough
Yes
No
Morning Cough
Yes
No
Shortness of Breath
Yes
No
Wheezing
Yes
No
Other Systemic
Diabetes
Yes
No
Excessive thirst/hunger
Yes
No
Thyroid
Yes
No
Kidney
Yes
No
Bladder
Yes
No
Frequency/burning
Yes
No
Gastrointestinal
Yes
No
Stomach absorptive disorder
Yes
No
Nausea, vomiting, diarrhea when taking antibiotics
Yes
No
Yeast infection when taking antibiotics
Yes
No
Arthritis/Joint Deformity
Yes
No
Arthralgia
Yes
No
Limited motion
Yes
No
Artificial joint
Yes
No
Convulsions, Epilepsy or Seizures
Yes
No
Fainting
Yes
No
Cardiovascular
High Blood Pressure
Yes
No
Chest Pain
Yes
No
Heart Attack
Yes
No
Heart Murmur
Yes
No
Irregular Heartbeat
Yes
No
Phlebitis
Yes
No
Inflamation of vein
Yes
No
Blood clots
Yes
No
Pacemaker
Yes
No
Infections
Tuberculosis (TB)
Yes
No
Oral Herpes Simplex
Yes
No
Fever blisters, cold sores
Yes
No
Genital Herpes Simplex
Yes
No
Shingles
Yes
No
Hepatitis A
Yes
No
Hepatitis B
Yes
No
Hepatitis C
Yes
No
HIV (AIDS)
Yes
No
Frequent infections
Yes
No
Skin
When you are exposed to sun do you
Tan only
Tan and burn
Burn
Have you ever had skin cancer?
Yes
No
Has anyone in your family had skin cancer?
*
Yes
No
If Yes, Who?
*
Do you have a history of any specific skin diseases?
*
Yes
No
If yes, please list
*
Do you develop skin rashes in reaction to Medications Food Environment?
List any other diseases or conditions
List surgical procedures you have had in the last 6 months
Social History
Do you drink alcohol?
*
Yes
No
If "yes" drinks per day
*
Do you use IV drugs?
*
Yes
No
If "Yes" What?
*
How much?
*
Do you smoke?
*
Yes
No
If "Yes" How Much?
*
Have you had or have you been exposed to HIV (AIDS)?
*
Yes
No
Please answer the following questions
A. Do you bleed easily?
*
Yes
No
B. (Women) Are you pregnant?
*
Yes
No
Due Date
*
-
Month
-
Day
Year
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C. What is your occupation?
D. What are your hobbies?
Completed by : Patient
Patient Signature
*
Clear
Patient Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
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Submit
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