PATIENT HISTORY FORM
Patient Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Primary Care Physician
*
First Name
Last Name
Referring Provider
First Name
Last Name
Occupation
Preferred Pharmacy
*
Pharmacy City
*
Pharmacy Phone Number
Please enter a valid phone number.
Mail Order Pharmacy
Past Medical History
*
Check all that apply
Abnormal Moles
Eczema
Asthma
Seasonal Allergies / Hayfever
Hypo / Hyper Thyroidism
Diabetes
Arthritis
Autoimmune Disorder
HIV
Cancer-List Type
Liver disease/Hepatitis
High Blood Pressure
Pacemaker
Mitral Valve Prolapse
Heart Valve Replacement
Joint Replacement
Blood Disorder
None of the Above
Do you have other medical conditions not listed above?
If you checked Cancer above, please list type here
Past Family & Personal Medical History
Personal
Family
Details
Basal Cell Carcinoma
Squamous Cell Carcinoma
Malignant Melanoma
Psoriasis
Past Surgical History and Hospitalizations: (List all)
Do you wear sunscreen?
*
Yes
No
If yes, SPF?
Do you use indoor tanning?
*
Yes
No
Never
Do you take any medications, including vitamins or supplements?
*
Yes
No
Medications: (Please enter all current medications and dosage, including vitamins, supplements, and birth control)?
Do you have allergies to medication?
*
Yes
No
If yes, please list and give type of reaction:
Number of alcoholic drinks per week?
*
None
Less than 1 per day
1-2 per day
3 or more per day
Are you are current smoker?
*
Yes
No
Number of packs per day
Currently
Former
Never
Alerts
Have you ever had a severe reaction to local anesthesia?
*
Yes
No
Are you allergic to adhesive?
*
Yes
No
Are you allergic to topical antibiotic ointments?
*
Yes
No
Are you taking blood thinners?
*
Yes
No
Have you been told to take antibiotics prior to dental or surgical procedures?
*
Yes
No
Do you get a rapid heartbeat with epinephrine?
*
Yes
No
Are you pregnant or planning a pregnancy?
*
Yes
No
If pregnant, due date
Skin Type
If you were first exposed to the summer sun without sunscreen, would you
*
1. Always burn, never tan
2. Always burn, sometimes tan
3. Sometimes burn, always tan gradually
4. Burn minimally, always tan well
5. Rarely burn, tan profusely
6. Never burn, deeply pigmented
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