MEDICAL HISTORY
Patient name: ___________________________________________________________________
Reason for today’s visit? ___________________________________________________________
- How long has this been a problem? _________________________________
- Have you tried any treatments or medications in the past for your current condition? YES NO
If yes, please list medications and over the counter items you have tried:
___________________________________________________________________________
Pharmacy Name/Address: _________________________________________________________
Current Medications If N/A - Circle NONE
Include prescriptions, over-the-counter meds (such as aspirin), vitamins, supplements and herbal
products:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Allergies
If N/A- Circle NONE
List all medications, seasonal/environmental, foods, adhesive, latex – and include reactions:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Female patients: Pregnant? ______ Planning a pregnancy? ______ Currently Breastfeeding? ______
Birth control? If yes, please list name of pill, or contraception method you are using currently:
_____________________________________________
Past Medical History: (Please circle all that apply)
Arthritis/Joint problems
GERD/Esophageal Reflux
Pacemaker
Anxiety
Hearing Loss
Radiation Treatment
Asthma
HIV infection/ AIDS
Seizures
Atrial Fibrillation (Irregular Heartbeat)
Hepatitis
Stroke
Blood clots or clotting disorder
Hypercholesterolemia
Varicose Veins
Bronchitis
Hypertension/blood pressure problems
Cancer (what type) ___________________
Hyperthyroidism
COPD
Hypothyroidism
Coronary Artery Disease
Leukemia
Depression
Lymphoma
Diabetes
Lupus
Fainting
Night Sweats
Other:________________________________________________________________________________
Past Surgical History: (Please circle all that apply)
Appendix Removed
Bladder
Breast: Mastectomy R L Both
Breast: Lumpectomy R L Both
Breast Biopsy
Breast Reduction
Breast Implants
Colectomy: Colon Cancer Resection
Colectomy: Diverticulitis
Colectomy: Inflamm. Bowel Disease
Gallbladder
Heart: Coronary Artery Bypass
Heart: Mechanical Valve Replacement
Skin Biopsy
Heart: Biological Valve Replacement
Skin Cancer:
Joint Replacement: Knee R L Both
Basal Cell
Joint Replacement: Hip R L Both
Squamous Cell
Kidney Biopsy
Melanoma
Kidney Removed R L Both
Spleen Removal
Kidney Stone Removal
Hysterectomy:
Ovaries Removed: Cyst
Fibroids
Tubal Ligation
Uterine Cancer
Endometriosis
Testicle Removal
Ovarian Cancer
Tonsillectomy
Prostate Removed: Cancer Other: _____________________
Personal Skin History: (Please circle all that apply)
Acne
Actinic Keratosis (Pre-cancers)
Asthma
Basal Cell Skin Cancer
Dry Skin
Eczema
Flaking or Itchy Scalp
Hay Fever/Allergies
Melanoma
Poison Ivy/Rashes
Atypical/“Pre-Cancerous” Moles
Squamous Cell Skin Cancer
Psoriasis
Warts
Cold Sores
Blistering Sunburns
Significant sunburns
Infection/MRSA
Tanning bed use? Current _____
Past ______
For how long/how often? ____________________________________________________
Sunscreen use (circle):
Daily
Occasionally
Only at the Beach
I don’t use sunscreen
Social History:
Smoking:
Current every day smoker _____
Current some day smoker (tobacco)____
Current some day smoker (cigarette)____
Alcohol:
None ______
1-2 drinks/day_____
Never Smoker_____
Former Smoker_____
less than 1 drink/day_____
3 or more drinks/day_____
Family History (blood relative i.e., grandmother, brother, child.)
Acne _______________________ Allergies/Hayfever _____________________________
Eczema _____________________ Psoriasis _____________________________________
Auto-Immune Disorders (thyroid, Lupus, M.S., Vitiligo) ______________________________
Other: _____________________________________________________________________
Skin Cancer _______________________________ Type? (Circle)
Basal Cell Carcinoma
Squamous Cell Carcinoma
Melanoma
Please check here if you are interested in receiving more information about:
Chemical Peels _____
Skin Care/Anti-Aging Products _____
Sun Protection/Sunscreens _____
Treatment of Excessive Underarm Sweating _____
Wrinkle relaxers (Botox, Dysport) _____
Spider Veins on the legs (Sclerotherapy) _____
Wrinkle fillers (Restylane, Juvaderm) _____
REQUEST FOR CONFIDENTIAL COMMUNICATIONS
I request that all communications to me (via telephone, mail or otherwise) by Hagerstown
Dermatology and Skin Care and/or its staff are handled in the following manner:
For written communications: (Mailing address)

________________________________________________________________
For oral communications: (Telephone number)

_______________________________________________________________________________

Email Address: ________________________________________________________________
Would you like to receive information on specials, or relevant information?  Yes  No
Do we have permission to:
Leave a message on your machine at home?  YES
Leave a message at your place of employment?
 NO
 YES
 NO
Discuss your Medical Condition or results with any member of your household?  YES
 NO
If Yes, Whom: _______________________________________________________________
Relationship:_________________________________________________________________
_________________________________________
____________________
Patient Signature
Date