Occupation (if any):________________________________
Place sticker here.
What is the reason your doctor sent you to see us?
.
________________________________________________
How long have you had this problem? _________________
How much of a problem is this condition for you? O Not at all O A little O Somewhat O Quite a lot O Extremely
What treatments have you used for this problem? ________________________________________________
Do you have any other medical problems? _____________________________________________________
What are your current medications?___________________________________________________________
Do you have any drug allergies? _____________________________________________________________
Do you have a family history of medical /skin problems?__________________________________________
Do you have a medication plan? (i.e. Green Shield):______________________________________________
Are you interested in clinical research trials regarding your condition? Yes □ No □
Section below for office use only--------------------------------------------------------------------------------Management:
Diagnosis:
______________________________________
______________________________________
______________________________________
Return visit: ____________
A/E’s: ____________________________
SPF _______
Info Pamphlet: Acne / Eczema / Psoriasis
Rosacea / Moles / Urticaria
Pre-op: __allergy to numbing
__artificial joints
__blood thinners
__heart murmur/valves
__fainting tendency
__pacemaker