Minor Patient Registration Form Page 2

ADVERTISEMENT

DERMATOLOGY HEALTH HISTORY
(Confidential)
Today’s Date ______________________________
Name ___________________________________________________
Birthdate _________________________________________________
Age _____________________________________
ALLERGIES:  NONE
SURGERIES: □ NONE
MEDICATIONS:
List all medications you are currently taking
Drug allergies: (list type of reaction)
List previous surgeries and dates
including prescriptions, over the counter products,
_________________________________
______________________________
vitamins and herbs.
Anesthetics
Aspirin
_____________________________
Codeine
Erythromycin
_______________________________
Penicillin
Sulfa
_____________________________
Tetracycline
Other
_______________________________
_____________________________
_______________________________
__ NON-DRUG ALLERGIES:
Food
Tape
________________________________
_____________________________
Anesthetic
Other
____________________________
FAMILY HISTORY
Do you or any member of your family now have, or ever had any of the following conditions:
Disease
Self
Family
Disease
Self
Family
Allergies
Heart disease
Arthritis
High blood pressure
Asthma
Lung disease
Cancer
Malignant melanoma
Diabetes
Psoriasis
Eczema
Skin cancer
Bleeding problems
Tuberculosis
SOCIAL HISTORY:
Check all that apply
Do you smoke?
No
Yes-Frequency __________
Do you use IV drugs?
No
Yes-Frequency __________
Have you had or been exposed to HIV (AIDS)?  yes  no
Do you drink alcohol?
No
Yes-Frequency __________
What is your occupation?
What are your hobbies: ________________________________________________
_____________________________________________________
HEALTH HISTORY QUESTIONS:
Have you been advised to take antibiotics before any surgery or dental work?……………………
YES
NO
Do you take blood thinners, anticoagulants or aspirin?………………………………………….
YES
NO
Did you ever take cortisone either by mouth or injection?…………………………………………
YES
NO
Have you ever had a blood transfusion?……………………………………………………………
YES
NO
Do you develop keloids (scars) after surgery? ……………………………………………………...
□ YES
□ NO
Do you have ANY type of pets at home? …………………………………………………………..
□ YES
□ NO
□ YES
□ NO
(Women) Are you pregnant?...............................................................................................................
Have you ever been examined by a Dermatologist before?…………………………………………
YES
NO
Have you ever been treated for the same condition for which you are being seen?………………..
YES
NO
Is there any other information that you feel is important for the doctor in evaluating your medical condition
YES
NO
Explain yes answers ________________________________________________________________________________________________
_________________________________________________________________________________________________________________
Why are you seeing the doctor today?____________________________________________________________________________________________
I certify that the above information is correct to the best of my knowledge. I will not hold my doctor or any members of his/her staff responsible for any errors or omissions
that I may have made in the completion of this form.
__________________________________________________________
_______________________
Signature
Date
Completed by: □Patient
□ Medical Assistant ________
_________________ Date ________________________
I have reviewed this patient health history form:
(initial)
(physiican initials)

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Patient Registration Form (minor) Patient Registration Form (minor) Medical
Minor Patient Registration Information Form Minor Patient Registration Information Form Medical
Application Form For Registration Of Minor Patient Form - Michigan Department Of Community Health Application Form For Registration Of Minor Patient Form - Michigan Department Of Community Health Medical
Patient Registration Form Patient Information Patient Registration Form Patient Information Medical
Patient Registration Form Patient Registration Form Medical
Patient Registration Form - American Dental Association Patient Registration Form - American Dental Association Business
Patient Registration Form - Chester County Eye Care Patient Registration Form - Chester County Eye Care Medical
Patient Registration Form Patient Registration Form Medical
Patient Registration Form Account - Baton Rouge Cardiology Center Patient Registration Form Account - Baton Rouge Cardiology Center Medical
Patient Registration Form Patient Registration Form Medical

Related Categories

Parent category: Medical
Download
Go
Page of 3