New Patient History Form
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1NEW PATIENT HISTORY
PATIENT’S NAME ___________________________________________________________________________AGE:_________
PARENT OR FINANCIALLY RESPONSIBLE PARTY ____________________________________________________________
REFERRING PHYSICIAN ____________________________________________________________________________________
REFERRING PHYSICIAN’S ADDRESS AND/OR TELEPHONE # ___________________________________________________
___________________________________________________________________________________________________________
HAVE YOU EVER HAD AN ALLERGIC REACTION TO ANY MEDICINE? _____YES ______NO
IF SO, PLEASE LIST
___________________________________________________________________________________________________________
DO YOU HAVE ANY PAST OR PRESENT HISTORY OF: (PLEASE ANSWER EVERY QUESTION)
YES___ NO___ PERSONAL HISTORY OR FAMILY HISTORY OF
YES___ NO___BLOOD DISEASE
SKIN DISEASE?
YES___ NO___HEART DISEASE
YES___ NO___ DO YOU HAVE A PACEMAKER?
YES___ NO___ENDOCRINE
YES___ NO___ ARE YOU REQUIRED TO TAKE ORAL ANTIBIOTICS
(hormonal problems)
BEFORE DENTAL WORK?
YES___ NO___ VENEREAL DISEASE
YES___ NO___ HIGH BLOOD PRESSURE
YES___ NO___ GASTROINTESTINAL
YES___ NO___ TUBERCULOSIS
DISEASE
YES___ NO___ GLAUCOMA
YES___ NO___ ARTHRITIS
YES___ NO___ DIABETES
YES___ NO___ POOR WOUND
YES___ NO___ ALLERGIES, such as Hayfever
HEALING (including discoloration or
YES___ NO___ ASTHMA
enlarged scars)
YES___ NO___ NEUROLOGIC DISORDERS
YES___ NO___ PULMONARY (lung
YES___ NO___ KIDNEY DISORDERS
disease)
YES___ NO___ LIVER DISORDERS
YES___ NO___ PERSONAL OR FAMILY HISTORY OF
YES___ NO___ BLEEDING DISORDERS
AUTOIMMUNE DISEASE SUCH AS LUPUS OR
YES___ NO___ NOVACAINE ALLERGY
SCLERODERMA
YES___ NO___ RECENT HOPSITALIZATION/SURGERY
YES___ NO___ HAVE YOU BEEN TESTED FOR
YES___ NO___ HAVE YOU HAD A SKIN CANCER?
H.I.V. VIRUS (AIDS)?
YES___ N0___ CANCER OTHER THAN SKIN?
YES___ NO___ ARE YOU PREGNANT OR
TYPE: _______________________
PLANNING PREGNANCY IN NEAR
FUTURE?
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, PLEASE GIVE DATES & EXPLAIN:
________________________________________________________________________________________________________
_________________________________________________________________________________________________________
LIST ALL MEDICATIONS, PRESCRIPTION AND NON-PRESCRIPTION, YOU ARE CURRENTLY TAKING:
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
LIST ANY MEDICATION TAKEN IN THE PAST TWO MONTHS. INCLUDE THOSE APPLIED TO THE SKIN. IF
MEDICATION HAS BEEN DISCONTINUED BEFORE THIS VISIT, PLEASE WRITE IN APPRXOIMATE DATES
THEY HAD BEEN TAKEN: _________________________________________________________________________________
_________________________________________________________________________________________________________
I CONSENT TO BE EVALUATED AND TREATED BY THE PHYSICIANS OF SKIN AND CANCER ASSOCIATES.
DATE: __________________ SIGNATURE: _____________________________________________________________________
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