Advanced Dermatology and Skin Surgery
MEDICAL HISTORY FORM
PATIENT to please fill out:
NAME: _________________________________________________ DATE: _________ BIRTHDATE:___/___/___
REFERRED BY: _________________________________________________________________________________
LIST OF CURRENT DR. & SPECIALISTS ___________________________________________________________
ALLERGIES: (DRUG, SEASONAL, AND FOOD ALLERGIES) _________________________________________
PHARMACY NAME/LOCATION:
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MEDICAL HISTORY: (Check the following medical conditions that you currently have)
 Anxiety
 Depression
 Leukemia
 Arthritis
 Diabetes
 Lung Cancer
 Asthma
 End Stage Renal Disease
 Lymphoma
 Atrial Fibrillation (Irregular Heartbeat)  GERD (Reflux Disease)
 Pacemaker/Defibrillator
 Bone Marrow Transplantation
 Hearing Loss
 Prostate Cancer
 BPH (Benign Prostatic Hyperplasia)
 Hepatitis
 Radiation Treatment
 Breast Cancer
 Hypertension (High Blood Pressure)
 Seizures
 Colon Cancer
 Hypercholesterolemia (High Cholesterol)  Stroke/TIA
 Pulmonary Disease/COPD
 HIV / AIDS
 Coronary Artery Disease/Heart Disease  Hyperthyroidism
 Hypothyroidism
 Other (Please List) ___________________________________________________
PAST SURGERIES:
 Appendix (Appendectomy)
 Heart: Transplant
 Prostate: Prostate Cancer
 Bladder (Cystectomy)
 Joint Replacement Knee Date:____R or L  Prostate: Prostate Biopsy
 Breast: (Mastectomy)
 Joint Replacement Hip Date:____R or L  Prostate: TURP
 Breast: Lumpectomy (Right/Left/Both)
 Kidney: Kidney Biopsy
 Rectum: Rectal Resection APR
 Breast: Breast Biopsy
 Kidney: Kidney Nephrectomy
 Rectum: Rectal Resection
 Colon (Colectomy) Colon Cancer Resection  Kidney: Kidney Stone Removal
 Skin: Skin Biopsy
 Colon (Colectomy) Diverticulitis
 Kidney: Kidney Transplant
 Skin: Basal Cell Carcinoma
 Colon (Colectomy): IBS
 Liver: Liver Transplant
 Skin: Squamous Cell Carcinoma
 Colon Colostomy
 Liver: Liver Shunt or Hepatectomy
 Skin: Melanoma
 Gallbladder (Cholecysectomy)
 Ovaries: Endometriosis
 Spleen: (Spenectomy)
 Heart: Coronary Artery Bypass Surgery
 Ovaries: Ovarian Cyst
 Testicles: (Orchidectomy)
 Heart: PTCA
 Ovaries: Ovarian Cancer
 Uterus(Hysterectomy):Uterine Cancer
 Heart Mechanical Valve Replacement
 Ovaries: Tubal Ligation
 Uterus(Hysterectomy):Cervical Cancer
 Heart: Bilogical Valve Replacement
 Pancreas: Pancreatectomy
Uterus(Hysterectomy):Fibroids
Other________________________________________________________
SKIN DISEASE HISTORY: Have you had any of the following skin conditions:
 Acne
 Dry Skin
 Poison Ivy
 Actinic Keratoses
 Eczema
 Precancerous Moles
 Asthma
 Flaking or Itchy Scalp
 Psoriasis
 Basal Cell Skin Cancer
 Hay Fever/Allergies
 Squamous Cell Skin Cancer
 Blistering Sunburns
 Melanoma
 Other: ____________________________________________________________________________________
Do you wear Sunscreen? Yes or No
PAGE 1 TURN OVER
If yes, what SPF? ____________
Do you tan in a tanning salon? Yes or No
FAMILY HISTORY:
Do you have a family history of Melanoma? Yes or No
If yes, which relative?___________________________
Do you have a family history of:
Autoimmune Disorder Carcinoma: Basal Cell Carcinoma: Squamous cell
Diabetes Eczema Psoriasis Hair Loss Hay fever/Asthma Other Cancer/Malignancy
(Please mark which relative & listed condition)
 Mother____________  Daughter______________  Nephew____________
 Grandmother_______________
 Father_____________  Son__________________  Niece______________
 Grandson___________________
 Sister______________  Uncle________________  Grandfather______________ Granddaughter________________
 Brother_____________  Aunt_________________  Other: __________________________________
SOCIAL HISTORY:
Occupation: _______________________ Place of Employment:________________________________
If Retired: Previous Occupation:____________________________________________
Social History Details
 Currently Smokes  Has smoked in the past  Smokes Every Day  Never Smoked  Smokes few times per week
 Drug/Alcohol Use Type: ____________________ How Often?____________________________
Exercise:
 1 time per day
 Few times per week
 Few times per month
 Never Exercise
REVIEW OF SYSTEMS:
Cardiovascular:
 Pacemaker
 Artificial Heart Valve
Allergic / Immunologic:
 Premedication prior to procedures
 Allergy to lidocaine
Endocrine:
 Pregnant or planning a pregnancy
Gastrointestinal:
 GI Upset with Antibiotics
Integumentary/Skin:
 Problems with Healing
 Changing Mole
 Defibrillator
 Artificial joints w/in past two years
 Rapid heartbeat with epinephrine  Chest Pain
 Allergy to adhesive
 Immunosuppression
Constitutional / Symptom:
 Yeast infections w/antibiotics
Hematologic / Lymphatic:
 Problems with bleeding
 Allergy to topical antibiotic ointments
 Fever or Chills
 Unintentional Weight Loss
 Problems with scarring (hypertrophic or keloid)
 Rash
PATIENT to please fill out:
Please provide your complete list of Current Medications (including aspirin, herbals, vitamins – DOSAGE NECESSARY):
Medication
Dosage
Reason
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