Dermatology Medical History
Patient Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Reason for visit
Are you allergic to any medications, anesthesia or latex?
*
Yes
No
If yes, please list.
List all medications you are currently taking (prescriptions, over-the-counter meds, vitamins, and herbals
Medical History: Have you had or currently have diseases in the following organs (If yes, please list):
*
Yes
No
Details
Asthma
Lungs (Other)
Blood Pressure
Heart Attack
Pacemaker
Heart (Other)
Diabetes
Thyroid
Kidney
Gastrointestinal
Arthritis
Lupus
Sarcoid
Artificial Joint
Neurologic
Stroke
Seizures
Cancer
Infections
Congenital
Other-explain in details column
Skin:
Have you ever had skin cancer?
*
Yes
No
Types?
Has anyone in your family had skin cancer?
*
Yes
No
Types?
Do you have a history of any specific skin diseases?
*
Yes
No
Types?
Do you have a family history of skin disease?
*
Yes
No
Types?
Do you develop keloids after surgery?
*
Yes
No
Do you bleed easily?
*
Yes
No
Do you develop skin rashes in reaction to:
*
Medications
Food
Environment
None
Social History:
Do you drink alcohol?
*
Yes
No
If yes, how many drinks per day and how many drinks per week?
Do you use IV drugs?
*
Yes
No
If yes, what?
Do you smoke?
*
Yes
No
Are you a former smoker?
*
Yes
No
If yes, when did you quit?
Do you have or have you been exposed to HIV (AIDS)?
*
Yes
No
Do you have or have you been exposed to Hepatitis C?
*
Yes
No
WOMEN - Are you pregnant?
*
Yes
No
I am not a woman
Due Date
-
Month
-
Day
Year
Date
What is your occupation?
What are your hobbies?
Digital Signature Authorization:
*
I certify that I am the person represented on this form or I have the legal authority to sign on their behalf. I also understand that the digital signature below is a valid legally binding signature.
Signature
*
Back
Next
Review of Systems
Check and explain if you have any of the following symptoms - check Yes to all that apply.
*
Yes
Explain
No
Fevers
Chills
Night Sweats
Swollen Lymph Nodes
Joint Pains: Specify New/Chronic
Nausea
Vomiting
Diarrhea
Constipation
Weight Loss/Gain
Heat/Cold Intolerance
Malaise/Fatigue
Chest Pains
Shortness of Breath
Palpitations
Cough
Wheezing
Edema
Dizziness
Seizures
Numbness/Tingling
Vision Changes
Hearing Changes
Easy Bruising/Bleeding
Digital Signature Authorization:
*
I certify that I am the person represented on this form or I have the legal authority to sign on their behalf. I also understand that the digital signature below is a valid legally binding signature.
Signature
*
Submit
FOR OFFICE USE: Reviewed by and date
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