The Dermatology Center Medical History Form Page 2

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CURRENT MEDICATIONS
Medication:
Dose:
Frequency:
Medication:
Dose:
Frequency:
Medication:
Dose:
Frequency:
Medication:
Dose:
Frequency:
MEDICATION ALLERGIES
□
Yes
□
No
Do you have any medication allergies:
List allergies and reactions:
FOR WOMEN ONLY
□
Yes
□
No
Are you pregnant?
□ Yes
□ No
Are you trying to become pregnant?
□ Yes
□ No
Are you breastfeeding?
□ Yes
□ No
Are you on birth control?
□ Yes
□ No
Do you have regular menstrual cycles?
FAMILY HISTORY OF SKIN CANCER
□
□
Do you have a family history of melanoma?
Yes
No
□
□
Do you have a family history of other skin cancer(s)?
Yes
No
Types:
SOCIAL HISTORY
Occupation:
□
□
□
Do you use sunscreen?
None
Daily
Occasionally
Lifetime No. Peeling Sunburns_______
Tanning bed use?
□
None
□
Current
□
Previous
□ Never □ Former □ Light □ Daily □ Occasional □ Heavy
□
Yes
□
No
Do you use tobacco?
□ Never □ 1x Month or less □ 2-4/Month □ 2-3/WK □ 4+/WK -- Daily: □1-2 □3-4 □5-6 □7-9 □10+
Alcohol consumption?
If 6+ Drinks: □Never □Occasional □Monthly □Weekly □Daily or Almost Daily
Do you have any other medical problems or conditions?
ADDITIONAL SYMPTOMS
Fever
□ Yes
□ No
Shortness of breath
□ Yes
□ No
Swollen
□ Yes
□ No
Chills
□ Yes
□ No
Nausea / vomiting
□ Yes
□ No
lymph nodes
Fatigue
□ Yes
□ No
Abdominal pain
□ Yes
□ No
Joint pain
□ Yes
□ No
Unintentional
□ Yes
□ No
Diarrhea
□ Yes
□ No
Rash / itch
□ Yes
□ No
weight loss
Constipation
□ Yes
□ No
Headache
□ Yes
□ No
Eye Irritation
□ Yes
□ No
Easy bruising
□ Yes
□ No
Anxiety
□ Yes
□ No
Chronic cough □ Yes
□ No
Blood clots
□ Yes
□ No
Depression
□ Yes
□ No
I understand the information above is an important part of my medical care and I have answered all of the above
questions truthfully and to the best of my abilities.
Patient, Parent or Guardian sign here _____________________________________________
Date_______________
PLEASE INDICATE ANY COSMETIC INTEREST OR CONCERNS
Wrinkles
□
Facial Redness
□
Tattoo removal □
Age Spots
□
Brown Spots
□
Acne Scarring
□
Sun Damage
□
Other ___________________
Spider Veins
Fat Reduction
Hair Removal
__________________________
□
□
□
Scars
Stretch Marks
Sagging Skin
__________________________
□
□
□
_____Thanks but no interest at this time

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