DERMATOLOGY MEDICAL HISTORY

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					                           2011 DERMATOLOGY MEDICAL HISTORY
Patient Name: _____________________________________                          Chart#: _____________
Date of Birth: ____________________________                                  Office: Bwk Cmd Jsp Blkshr

Reason for Today’s Visit: _______________________________________________________
Do you take any medications (prescription, over the counter, vitamins & herbals)? Yes  No
 If yes, please list below (include dosage or frequency if known) or attach list:  See List
  ____________________                         ______________________        ____________________
  ____________________                         ______________________        ____________________

Have you ever had dental or local anesthesia?           Yes  No            Any bad reaction? Yes  No
Are you allergic to anything, specifically medications?  Yes  No           If yes, list below:
  ________________________________________________________________________

Please answer the following questions to the best of your ability. Do you have now or ever had?
Skin:                                                                                    YES NO
Have you ever had skin cancer (Basal Cell, Squamous Cell, Merkel)?........                  
Have you ever had MELANOMA?................WHEN _________________                           
Do you have a history of any specific skin disease(s)?..................................    
Do you have trouble healing? Develop keloids (scars) after surgery?...........              
Do you have skin allergies to………………… Latex  Tape  Other ____________

Cardiovascular:                                  YES    NO       Other Systemic:             YES    NO
 Bleeding Problems ………………                                       Diabetes..……………                 
 High Blood Pressure……………..                                     Lungs…….………….                   
 Pacemaker………………………..                                           Thyroid. …………….                 
 Implantable Defibrillator…………                                  Kidney....………….…                
 Stroke…………………………….                                             Bladder……………..                  
 Heart Attack………………………                                          Yeast Infection………              
 Heart Murmur…………………….                                          Fainting…………..…                 
 Irregular Heartbeat …….…………                                    Lupus……………….                    
 Phlebitis (Inflammation of vein) …                             Nausea or diarrhea if taking
 Blood Clots..………………………                                           antibiotics or pain meds      
Infectious Diseases:                                              Gastrointestinal………             
 Hepatitis (A,B or C)………………                                      Arthritis………………                
 MRSA……………………………                                                Artificial joint………             
 HIV (AIDS) ……………………….                                          Convulsions, Epilepsy or
 TB (Tuberculosis)…………………                                          Seizures………..……              

List any other significant disease or conditions not listed above: _____________________________

Family History:                                                                              YES    NO
 Has anyone in your family had melanoma? …………………………………….                                           
Social History:                                   YES   NO
 Do you smoke?..............................                If yes, how much: _____________________
 Do you drink alcohol?...................                   If yes, no. of drinks per day______________
 Do you use sunscreen?..................                    If yes, how often ______________________
 Are you pregnant (women)?........                          If yes, expected due date? _______________

What is your occupation? _____________________________               Hobbies? ______________________

Patient Signature: _______________________________ Date Completed: _____________
Parent Signature (if minor): _________________________
                                                       Reviewed by: [_____] Date:

				
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posted:9/15/2012
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