Medical History Page 2
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2FAMILY HISTORY OF MEDICAL DISEASES
Cancer ..........................................Y N
Arthritis ............................................ Y N
High blood pressure .....................Y N
Diabetes .......................................... Y N
Heart disease ...............................Y N
Allergy/hay fever/sinus .................... Y N
Stroke ...........................................Y N
Family history of skin diseases ....... Y N
Other: ______________________________________________________________________________
LIST PAST SURGERIES AND APPROXIMATE TIME/AGE
___________________________________________________________________________________
___________________________________________________________________________________
PLEASE ANSWER THE FOLLOWING
1. Do you smoke/chew tobacco? ........... Y N
How much? ___________________________________
2. Do you use recreational drugs? ......... Y N
Which drug(s)? ________________________________
3. Do you bleed easily/aspirin ................ Y N
4. Any artificial joints? ............................ Y N
Where? ______________________________________
5. Women:
Are you pregnant? ............................ Y N
Due date ________________________
Breast feeding?................................. Y N
Are you on the Pill? .......................... Y N
Depoprovera shots?
Y N
Estrogen?
Y N
Progesterone? .................................. Y N
SKIN HISTORY
1. Where did you grow up? _____________________________ Were you a lifeguard?
Y N
2. How many blistering sunburns did you get before age 21? ____
3. Anyone in your family have skin cancer? ... Y N
Basal cell .............................................. Y N
Squamous cell ...................................... Y N
Melanoma ............................................ Y N
Pre cancer ............................................ Y N
4. Have you had skin cancers? ...................... Y N
Basal cell .............................................. Y N
Squamous cell ...................................... Y N
Melanoma ............................................ Y N
Pre cancer ............................................ Y N
5. Do you have a history of skin disease? ...... Y N
6. Any other diseases or conditions we should know about? Please describe:
________________________________________________________________________________
7. Do you use sunscreen regularly? ............... Y N
8. Any surgery done in the past 6 months? .... Y N If yes, what and when:
________________________________________________________________________________
9. What is your occupation? ____________________________________________________________
10. What are your hobbies? _____________________________________________________________
Completed by: ____Patient
____Other relationship _____________
____Medical assistant
Reviewed by: ___________________________________________
Date: ____________________
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