Patient Medical History Form
Patient Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date of Birth
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Year
Age
*
Gender
*
Please Select
Male
Female
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Occupation
Home Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Cell Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Work Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
I wish to be contacted in the following manner (Check all that applies)
Home Telephone
Home Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Work Phone
Work Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Cell Phone
Cell Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Leave message with call back number and appointment confirmation only.
OK to leave a message with detailed information
OK to fax information as needed to this fax number
Fax Number
*
Format: (000) 000-0000.
Additional family members if any, who we may contact
Name
Name
Emergency Contact
Name
*
Relationship
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
How did you hear about Seriously Skin
*
Please Select
Doctor
Friend
Internet
Groupon
Living Social
Chagrin Valley Times
Currents
Billboard
Other
Select as many as apply
Doctor's Name
*
Friend's Name
*
If "Other" Please Explain
*
PATIENT IS RESPONSIBLE FOR PROVIDING ANY NECESSARY CHANGES TO THIS FORM
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Medical History
Patient Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Past Medical History
Do you have now, or have you ever had diseases or conditions of (please select yes or no)
Anxiety
*
Yes
No
When?
*
Arthritis
*
Yes
No
When?
*
Asthma
*
Yes
No
When?
*
Atrial Fibrillation
*
Yes
No
When?
*
Bipolar Disorder
*
Yes
No
When?
*
Blood Clots
*
Yes
No
When?
*
Bone Marrow Transplant
*
Yes
No
When?
*
Breast Cancer
*
Yes
No
When?
*
Cataracts
*
Yes
No
When?
*
Colon Cancer
*
Yes
No
When?
*
COPD (Emphysema)
*
Yes
No
When?
*
Coronary Artery Disease
*
Yes
No
When?
*
Depression
*
Yes
No
When?
*
Diabetes
*
Yes
No
Type and When?
*
End Stage Renal Disease
*
Yes
No
When?
*
GERD (Acid Reflux)
*
Yes
No
When?
*
Glaucoma
*
Yes
No
When?
*
Heart Murmur or Mitral Valve Prolapse
*
Yes
No
When?
*
Heart Valve Replacement
*
Yes
No
When?
*
Hepatitis (A, B, or C)
*
Yes
No
When?
*
Hypertension (High Blood Pressure)
*
Yes
No
When?
*
HIV / AIDS
*
Yes
No
When?
*
Hypercholesterolemia (High Cholesterol)
*
Yes
No
When?
*
Hyperthyroidism
*
Yes
No
When?
*
Hypothyroidism
*
Yes
No
When?
*
Leukemia
*
Yes
No
When?
*
Lung Cancer
*
Yes
No
When?
*
Lymphoma
*
Yes
No
Type
*
Pacemaker or Defibrillator
*
Yes
No
When?
*
Polycystic Ovary Syndrome (PCOS)
*
Yes
No
When?
*
Radiation Treatment
*
Yes
No
When?
*
Seasonal Allergies
*
Yes
No
When?
*
Seizures
*
Yes
No
When?
*
Sexually Transmitted Infection
*
Yes
No
Type
*
Stroke
*
Yes
No
When?
*
Other
*
Yes
No
If "Other" Please Explain
*
Past Surgical and Medical History
Do you have now, or have you ever had diseases or conditions of (please select yes or no)
Appendix Removed
*
Yes
No
When?
*
Bladder Removed
*
Yes
No
When?
*
Mastectomy (Right or Left or Bilateral)
*
Yes
No
When?
*
Lumpectomy (Right or Left or Bilateral)
*
Yes
No
When?
*
Breast Implants
*
Yes
No
When?
*
Capsular Contracture
*
Yes
No
When?
*
Colon Cancer Resection
*
Yes
No
When?
*
Diverticulitis
*
Yes
No
When?
*
Irritable Bowel Syndrome
*
Yes
No
When?
*
Eaton-Lambert Syndrome
*
Yes
No
When?
*
Coronary Artery Bypass
*
Yes
No
When?
*
PTCA (Angioplasty)
*
Yes
No
When?
*
Heart Valve Replacement (Mechanical or Biological)
*
Yes
No
When?
*
Heart Transplant
*
Yes
No
When?
*
Joint Replacement
*
Yes
No
When?
*
Kidney Transplant
*
Yes
No
When?
*
Ovarian Cancer
*
Yes
No
When?
*
Skin Biopsy
*
Yes
No
When?
*
Basal Cell Carcinoma Surgery (Mohs or Excision)
*
Yes
No
When?
*
Squamous Cell Carcinoma Surgery (Mohs or Excision)
*
Yes
No
When?
*
Melanoma Surgery
*
Yes
No
When?
*
Spleen Removal
*
Yes
No
When?
*
Hysterectomy
*
Yes
No
When?
*
Allergy to Pork or Cows Milk
*
Yes
No
When?
*
History of Herpes Simplex
*
Yes
No
When?
*
Keloids
*
Yes
No
When?
*
Myestheniagrams
*
Yes
No
When?
*
Autoimmune Disease
*
Yes
No
When?
*
Myasthenia Gravis
*
Yes
No
When?
*
Convulsions / Epilepsy
*
Yes
No
When?
*
Skin Cancer
*
Yes
No
When?
*
Problems with skin healing
*
Yes
No
When?
*
Keloid Scars
*
Yes
No
When?
*
Bruise Easily
*
Yes
No
When?
*
Please list all skincare products you are currently using.
Females Only (OB/GYN)
Pregnant
*
Yes
No
If yes, how many weeks?
*
Breast Feeding
*
Yes
No
Planning Pregnancy
*
Yes
No
Family History
Melanoma
*
Yes
No
If yes, which relative?
Current Medications (RX LISTED ON 2ND PAGE)
Aspirin (81 mg or 325 mg)
*
Yes
No
NSAIDs (Motrin, Ibuprofen, Aleve, Advil)
*
Yes
No
Multivitamins / Supplements
*
Yes
No
Please list Multivitamins and Supplements
Skin History
Acne
*
Yes
No
Duration
*
X-ray or UV Light Treatment for Acne
*
Yes
No
Actinic Keratoses
*
Yes
No
Asthma
*
Yes
No
Basal Cell Skin Cancer
*
Yes
No
Blistering Sunburns
*
Yes
No
Dry Skin
*
Yes
No
Psoriasis
*
Yes
No
Eczema
*
Yes
No
Flaking or Itchy Scalp
*
Yes
No
Hay Fever / Allergies
*
Yes
No
Melanoma
*
Yes
No
Poison Ivy
*
Yes
No
Precancerous Moles (Atypical Moles)
*
Yes
No
Squamous Cell Skin Cancer
*
Yes
No
Tattoos
*
Yes
No
Other
*
Yes
No
If "Other" Please Explain
*
Social History
Cigarette Smoking
Never Smoked
Quit: Former Smoker
Smoke: Less Than Daily
Smoke: Daily
Alcohol Use
None
Less than 1 drink per day
1-2 drinks per day
3 or more drinks per day
Surgical tx: list surgeries below
Laser Hair Removal History: list below
Skin Type
White
Black / African American
Asian
American Indian or Native Alaskan
Native Hawaiian / Pacific Islander
Unknown
Suntanning
Do you suntan?
Never
Occasionally
Regularly
Do you Sunbed Tan?
Never
Occasionally
Regularly
Are you currently using
Retin-A, Tazerac, Differin, Hydroquinone
*
Yes
No
If so, which product?
*
Any other topical skin exfoliation or bleaching agent
*
Yes
No
If yes, please list
Have you ever had plastic surgery on your face or neck areas?
*
Yes
No
If so, please explain
*
Date or surgery
*
Have you ever had Botox / Dysport / Xeomin / Jeuveau / Daxxify before?
*
Yes
No
Have you ever had eyelid droop after Botox / Dysport / Xeomin / Jeuveau / Daxxify?
*
Yes
No
Do you show a lot of upper lid when eyes are open?
*
Yes
No
Do your eyelids feel extra heavy when you don't get enough sleep?
*
Yes
No
Do your eyelids droop without sleep?
*
Yes
No
Have you ever had injectable fillers, collagen, or collagen stimulators before?
*
Yes
No
Have you ever had laser skin treatments or laser hair removal?
*
Yes
No
If so what was the treatment
*
Have you ever had a chemical peel, microdermabrasion, or other skin resurfacing treatments?
*
Yes
No
If so, what treatment
*
Have you ever been treated for pigmented lesions?
*
Yes
No
Do you form thick or raised scars from cuts or burns?
*
Yes
No
Do you experience hyperpigmentation (redness) from acne, burns, cuts, or insect bites?
*
Yes
No
Have you ever had cold sores or fever blisters?
*
Yes
No
Are you currently taking any prescription medications?
*
Yes
No
If yes, please list ALL prescriptions
Are you currently taking any vitamins / supplements?
*
Yes
No
If yes, please list ALL vitamins / supplements
*
Do you take antibiotics BEFORE teeth cleanings or dental procedures
*
Yes
No
Do you have ANY allergies to medications
*
Yes
No
If so, please list
Pharmacy
Pharmacy Name
*
Pharmacy Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Pharmacy Cross Street
*
Patient Signature
*
Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Submit
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