Medical History

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Alpine Dermatology Associates, P.L.L.C.
1785 Kipling
Lakewood, Colorado 80215
(303) 935-4681
MEDICAL HISTORY
Primary Doctor _______________________________________________________________________
Referred by __________________________________________________________________________
Patient Name ______________________________________________
Date ___________________
Are you allergic to any medications?
Yes/No If yes, please list:
1.
3.
2.
4.
LIST ALL MEDICATIONS (PRESCRIPTION, OVER THE COUNTER, HERBAL) YOU ARE
CURRENTLY TAKING:
1.
4.
2.
5.
3.
6.
HISTORY OF MEDICAL PROBLEMS
Do you have or have you ever had problems with…Circle (Y)es or (N)o:
Systemic
Diabetes .......................................Y N
Seizures/epilepsy ............................ Y N
Thyroid .........................................Y N
Fainting ........................................... Y N
Kidney/urinary tract ......................Y N
Glaucoma/eyes ............................... Y N
Stomach .......................................Y N
Alcoholism ....................................... Y N
Bowels/gall bladder ......................Y N
AIDS exposure ................................ Y N
Liver/spleen/hepatitis ...................Y N
Phlebitis .......................................... Y N
Allergies/hay fever/sinus ..............Y N
Arthritis ............................................ Y N
Lungs
Vascular
Asthma .........................................Y N
High blood pressure ........................ Y N
Emphysema .................................Y N
Chest pain ....................................... Y N
Bronchitis......................................Y N
Heart attack ..................................... Y N
Morning cough .............................Y N
Heart murmur .................................. Y N
Chronic cough ..............................Y N
Irregular/fast heart beat .................. Y N
TB/clots in lungs ...........................Y N
Pacemaker ...................................... Y N
Other: ______________________________________________________________________________

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