Medical History Form
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1
2MEDICAL HISTORY FORM
Today’s date:
MD:
PATIENT INFORMATION
Last name:
First:
Middle:
Birth date:
/
/
Primary Language:
□ English □ Arabic □ French □ German □ Mandarin □ Spanish □ Russian □ Other
Race:
□ American Indian □ Asian □ African American or Black □ Native Hawaiian/Other Pacific □ White □ Unknown □ Other
Ethnicity:
□ Hispanic or Latino
□ Not Hispanic or Latino
Primary Pharmacy:
Address:
REASON FOR TODAY’S VISIT
Concern:
Location:
Duration:
Prior Treatments:
Concern:
Location:
Duration:
Prior Treatments:
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
□ Yes
□ No
Heart disease
□ Yes
□ No
Anticoagulant treatment
Bleeding disorders
□ Yes
□ No
Diabetes
□ Yes
□ No
Artificial joint
□ Yes
□ No
Kidney disease
□ Yes
□ No
Artificial heart valves
□ Yes
□ No
Thyroid disease
□ Yes
□ No
□ Yes
□ No
Lupus
□ Yes
□ No
Pacemaker / defibrillator
Mitral valve prolapsed
□ Yes
□ No
Arthritis
□ Yes
□ No
Immunosuppressed
□ Yes
□ No
Psoriasis
□ Yes
□ No
Organ transplant
□ Yes
□ No
High blood pressure
□ Yes
□ No
Cancer
□ Yes
□ No
Seizure / Epilepsy
□ Yes
□ No
Pre-op/pre-dental antibiotics
□ Yes
□ No
□ Yes
□ No
Stomach Ulcer/Intestinal
Memory problems
□ Yes
□ No
Glaucoma/eye disease □ Yes
□ No
Fainting / syncope
□ Yes
□ No
Tuberculosis/Lung Dz
□ Yes
□ No
Hepatitis or liver disease
□ Yes
□ No
Venereal disease
□ Yes
□ No
HIV positive
□ Yes
□ No
Hives
□ Yes
□ No
MRSA
□ Yes
□ No
□ Yes
□ No
Mole change color/shape/size
□ Yes
□ No
Other
_____________
Prior Hospitalizations & Surgery
Dates:________________________________
MELANOMA HISTORY
Do you have a history of melanoma?
□
□
Date:________ Location:____________
Yes
No
Do you have a history of other skin
□ Yes
□ No Type:____________
Date:________Location:_____________
cancer(s)?
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