Medical History Form
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Medical History
Date: ___________________
Last Name: ___________________________________ First Name: ________________________________
Street Address: ___________________________________________________________________________
City: _____________________________________State: __________________Zip: ___________________
Telephone: Home: _______________________________ Age: ____________D.O.B ______________
Work: _____________________________Email: __________________________________
Cell: _____________________________ Txt Messaging Y ____ N____ Service with____________
Primary Care Doctor: _________________________________Phone: _____________________________
How did you hear of us: Sign_____Internet Search:
_____________Referred by:___________________
(specify)___
Please answer ALL the following questions.
YES
NO
_____
_____
1. Do you have ANY current or chronic medical history we should know about?
Please list: ___________________________________________________
___________________________________________________
2. Do you take ANY medication on a regular basis? And what for??
_____
_____
Please list: ___________________________________________________
3. Do you have ANY allergies to medicine or skin sensitivities?
_____
_____
Please list: ___________________________________________________
4. Are you pregnant? Or planning to be? ________________
_____
_____
5. To determine skin type, check one of the following:
Type
Color
Reaction to first sun exposure yearly
_________I
White
Always burn/never tan
_________II
White
Usually burn/tan with difficulty
_________III
White
Sometimes mild burn/tan with ease
_________IV
Med. Brown
Rarely burn/tan with ease
_________V
Dark Brown
Rarely burn/tan very easily
_________VI
Black
Never burn/tan very easily
Section A: Laser Treatments/Dermatology/Skin Problems
YES
NO
1
Have you taken Accutane in the last year?
_____
_____
If so, when was the last time it was taken: ___________________
2
Do you have a history of cold sores/fever blisters on the face?
_____
_____
If so, have you taken Valtrex before?
_____
_____
3
Have you had any reaction to novacaine or lidocaine before?
_____
_____
4
Have you ever received laser treatments for a skin problem?
_____
_____
5
Have you ever had a chemical peel, dermabrasion, collagen
_____
_____
injection, face lift, eyelift, or other plastic surgical procedure?
_____
_____
Please list with date & with whom: _____________________________________________
6
Have you ever had any skin problems before?
_____
_____
Specify: Eczema, psoriasis, rashes….) __________________________________________
7
Is there a history of abnormal moles, skin cancer, etc. in you or
_____
_____
your family? If yes, who? ___________________________________________________
8
Have you shown abnormal pigmentatation or scarring after
_____
_____
previous operations? ______________________________________________________
9
Do you go to a tanning salon? Last time: ________________
_____
_____
Go to
10
Are you taking any aspirin or blood thinners?
_____
_____
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Parent category: Medical