DERMATOLOGY MEDICAL HISTORY
Patient:  ________________________________________								Date: _____/_____/_____
What is your reason for todays visit? ____________________________________________________________
Are you allergic to any medications?				Yes	No	If yes, please explain below
1) __________________________________________					2) ___________________________________________
Have you ever had dental anesthesia?				Yes	No	Any bad reactions?			Yes	No
List all medications you are currently taking (including prescriptions, over-the-counter meds., vitamins and herbals):
1) ______________________				3) _______________________				1) ______________________
2) ______________________				4) _______________________				2) ______________________
Do you have now, or have you ever had diseases or conditions of: (Please check yes or no)
Lungs					Other Systemic
Bronchitis			Yes	No	Diabetes				Yes	No
Emphysema			Yes	No	Stroke				Yes	No
Asthma			Yes	No	Thyroid Disorder				Yes	No
Chronic cough			Yes	No	Kidney Disease				Yes	No
Seasonal Allergies			Yes	No	Organ Transplant				Yes	No
Shortness of breath			Yes	No	Immune System Disorder				Yes	No
					Bleeding or Blood Disorder				Yes	No
Cardiovascular					Liver Disease				Yes	No
High Blood Pressure			Yes	No	Gastrointestinal Disorder				Yes	No
Chest Pain			Yes	No	Autoimmune Disease				Yes	No
Heart Attack			Yes	No	Yeast infection when
Heart Murmur			Yes	No	taking antibiotics				Yes	No
Irregular hear beat			Yes	No	Arthritis/ Joint Deformity				Yes	No
Phlebitis			Yes	No	Artificial Joint				Yes	No
Inflamation of vein			Yes	No	Convulsions, Epilepsy or Seizures				Yes	No
Blood Clots			Yes	No	Fainting				Yes	No
Pacemaker			Yes	No
List any other diseases or conditions _____________________________________________________________
List any surgical procedures you have had in the past six months _____________________________________
Skin:
Have you ever had skin cancer?						Yes	No	Type______________
Has anyone in your family had skin cancer?						Yes	No	Type______________
Do you have a history of any specific skin diseases?						Yes	No
Do you have problems with healing?						Yes	No
Do you develop keloids (scars) after surgery?						Yes	No
Do you have a history of blistering sunburns?						Yes	No
Do you have a history of tanning bed use?						Yes	No
Social History:
Do you drink alcohol?			Yes	No	If yes ___________ drinks per day
Do you use IV drugs?			Yes	No	If yes, what? ______________  How often? ______________
Do you smoke?			Yes	No	If yes, how much? _____________________
Have you had or have you been exposed to HIV (AIDS)?						Yes	No
Please answer the following questions:
(Women) Are you pregnant?				Yes	No	Due Date:  ____ / ____ / ______
What is your occupation? _____________________________						Hobbies?  _______________________
Completed by:		Patient			_______________________________				_____/_____/_____
		Medical Assistant ______			Signed by Patient				Date
					________________________________				_____/_____/_____
					Reviewed by				Date