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
Your Occupation
Preferred Pharmacy
*
Pharmacy Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Pharmacy Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Mail Order Pharmacy
Do you take any prescription medications, including vitamins or supplements?
Yes
No
If yes, please list below
Do you have allergies to medication?
Yes
No
If yes, please list and give type of reaction
Rows
Allergic to
Reaction
1.
2.
3.
4.
5.
Past Medical History
*
Rows
Yes
No
Abnormal Moles
Eczema
Asthma
Seasonal Allergies / Hayfever
Hypo / Hyper Thyroidism
Diabetes
Arthritis
Autoimmune Disorder
HIV
Cancer-List Type below
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
Rows
Personal
Family
Details
Basal Cell Carcinoma
Squamous Cell Carcinoma
Malignant Melanoma
Psoriasis
Past Surgical History and Hospitalizations: (List all)
Please check YES or NO
Rows
Yes
No
Do you wear sunscreen?
Do you use indoor tanning?
Have you ever had a severe reaction to
local anesthesia?
Are you allergic to adhesive?
Are you allergic to topical antibiotic ointments?
Are you taking blood thinners?
Have you been told to take antibiotics prior
to dental or surgical procedures?
Have you had an adverse reaction to epinephrine?
Are you planning a pregnancy?
Number of alcoholic drinks per week?
*
None
Less than 1 per day
1-2 per day
3 or more per day
Smoking Status
*
Current, everyday
Current, some days
Former
Never
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
Submit
Should be Empty: