The Dermatology Center Medical History Form

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THE DERMATOLOGY CENTER MEDICAL HISTORY FORM
Today’s date:
Doctor/PA/NP:
PATIENT INFORMATION
Last name:
First:
Middle:
Birth date:
Gender:
/
/
□ Male
□ Female
Primary Pharmacy:
Pharmacy Address/Phone:
REASON FOR TODAY’S VISIT
Concern:
Location:
Duration:
Prior Treatments:
Concern:
Location:
Duration:
Prior Treatments:
PAST MEDICAL HISTORY
Adhesive tape allergy
□ Yes
□ No
Abnormal scars
□ Yes
□ No
Latex allergy
□ Yes
□ No
Poor wound healing
□ Yes
□ No
□ Yes
□ No
HSV / cold sore
□ Yes
□ No
Local anesthetics allergy
Epinephrine sensitivity
□ Yes
□ No
Eczema
□ Yes
□ No
Bacitracin allergy
□ Yes
□ No
□ Yes
□ No
Asthma
Neosporin allergy
□ Yes
□ No
Hay fever
□ Yes
□ No
Anticoagulant treatment
□ Yes
□ No
Heart disease
□ Yes
□ No
Bleeding disorders
□ Yes
□ No
High blood pressure
□ Yes
□ No
Artificial joint
□ Yes
□ No
Diabetes
□ Yes
□ No
Artificial heart valves
□ Yes
□ No
Kidney disease
□ Yes
□ No
□ Yes
□ No
Thyroid disease
□ Yes
□ No
Pacemaker / defibrillator
Mitral valve prolapse
□ Yes
□ No
Lupus
□ Yes
□ No
Immunosuppressed
□ Yes
□ No
Arthritis
□ Yes
□ No
Organ transplant
□ Yes
□ No
Psoriasis
□ Yes
□ No
CLL Chronic leukemia
□ Yes
□ No
Acid Reflux
□ Yes □ No
Pre-op/pre-dental antibiotics
□ Yes
□ No
New/changing/abnormal moles
Memory problems
□ Yes
□ No
□ Yes
□ No
Fainting / syncope
□ Yes
□ No
Hair/Nail problems
□ Yes
□ No
Hepatitis
□ Yes
□ No
Previous Surgery _____________________
HIV positive
□ Yes
□ No
________________________________________
MRSA
□ Yes
□ No
Cancers other than skin □ Yes □ No
Current Flu shot □ Yes □ No Date Received: ________________________
Pneumonia shot □ Yes □ No
If Yes, type
Date Received: ____________________
_____________________
SKIN CANCER HISTORY
Yes
No
Do you have a history of melanoma?
□ Yes
□ No
Do you have a history of other skin cancer(s)?

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