Patient Name:
Date of Birth:
Past Medical History (patient): (please check all that apply)
o Actinic Keratosis
o Bleeding disorder
o GERD
o Alzheimer’s
o Blood clots
o Graves Disease
Dementia
o Cancers
o Headaches
o Anemia
o COPD
o Heart disease/CAD
o Anxiety
o CVA (stroke)
o Hepatitis C
o Arthritis
o Depression
o High cholesterol
o Asthma
o Diabetes
o Hypertension
o Atrial Fibrillation
o Eczema
o Hyperthyroidism
Do you have history of skin cancer? NO
YES
Type:
Have you had a flu shot in the past 12 months? NO
YES
Date:
Are you at risk for falling?
NO
YES
If you are 65 or older, have you received the pneumococcal Vaccine? (pneumonia vaccine)
Other medical problems:
Ht:
o
o
o
o
o
o
o
o
Wt:
o
o
o
o
o
o
Hypothyroidism
Irregular heart rate
Liver Disease
Mental disorder
Multiple Sclerosis
Otosclerosis
Psoriasis
Rosacea
○ NO
○ YES
Seizure disorder
Sleep Apnea
Thyroid disease
Tinnitus
Tuberculosis
Vertigo
Date:
Past Surgical History: (please list with date)
Social History:
Do you smoke cigarettes?
 Current
Do you drink alcohol?
Do you use recreational drugs?
Do you drink caffeine?
Are you currently pregnant?
Recent changes in your sleep pattern?
Marital Status:
 Single
Do you have children?
 Yes
 Never
 In the past
# per day/week
#years
 Yes
 No
# drinks
Per
Day
 Yes
 No
Type:
 Yes
 No
 Yes
 No
Are you currently breast feeding?
 Yes
 Yes
 No
 Married
 Divorced
 Separated
 Widowed
 No
Week
 No
 Partnered
Family History:
Skin Cancer
Allergies
Asthma
Autoimmune disease
Cancer
COPD
Dermatitis
Diabetes
 No
 No
 No
 No
 No
 No
 No
 No
 Yes
 Yes
 Yes
 Yes
 Yes
 Yes
 Yes
 Yes
relative:
relative:
relative:
relative:
relative:
relative:
relative:
relative:
 No
 No
 No
 No
 No
 No
 No
 No
Eczema
Hearing disorder
Hepatitis
Keloids
Otosclerosis
Psoriasis
Rosacea
Thyroid disease
 Yes
 Yes
 Yes
 Yes
 Yes
 Yes
 Yes
 Yes
relative:
relative:
relative:
relative:
relative:
relative:
relative:
relative:
Medications: Do you take any prescription/non-prescription medications or supplements?
 No
 Yes (please list)
Allergies: Do you have any allergies or sensitivities to medications that you know of?
 No
 Yes (please list)
Patient Signature:
Date:
FOR FUTURE USE: By signing below I am verifying that I have reviewed my medical history and have verified there are no changes.
Patient Signature:
Date:
Patient Signature:
Date:
Patient Signature:
Date:
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