Patient Name______________________________________ Date__________________
Sex____M____F Age_____ Height_____ Weight______
Are you allergic to any medications? ___yes ___no If yes please list below:
1.________________________ 2._________________________
3.________________________ 4._________________________
List ALL medications you are currently taking (including prescriptions, over the counter, vitamins, and herbals):
1.________________
4.________________
7.________________
2._________________
5._________________
8._________________
3.________________
6.________________
9.________________
Do you have now, or have you ever had any of the following diseases or conditions:
(please circle Y for yes and N for no)
Lungs: YES NO Other Systemic: YES NO
Bronchitis
Emphysema
Asthma
Chronic Cough
Morning Cough
Shortness of Breath
Wheezing
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
Diabetes Y
Excessive thirst/hunger Y
Thyroid Y
Kidney
Bladder
Frequency/Burning
Gastrointestinal/Stomach
Y
Y
Y
N
N
N
N
N
N
Cardiovascular:
High Blood Pressure
Chest Pain
Heart Attack
Heart Murmur
Phlebitis
Irregular Heartbeat
YES NO
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
absorptive disorder
Nausea, vomiting, diarrhea
when taking antibiotics Y
Yeast infection when
taking antibiotics
Limited Motion
Y
Y
Arthritis/Joint Deformity Y
Arthralgia Y
Y
N
N
N
N
N
N
N Inflammation of vein
Blood clots
Pacemaker
Y
Y
Y
Skin: (please circle your answer)
When you are exposed to sun do you:
Have you ever had skin cancer?
N
N
N
Artificial joint
Convulsions, Epilepsy, or
Seizures
Fainting
Y
Y
Y
N
N
Malignant Melanoma?
Has anyone in your family had skin cancer?
Malignant Melanoma?
Tan only
Yes
Yes
Yes
Yes
Tan and burn
No
No
No
No
Burn
If yes, who?____________________________________________________________________________

Do you have a history of any specific skin disease? YES NO
(please circle your answer)
If yes, please list:________________________________________________________________________
Are you currently receiving any treatment for any specific skin diseases?
(please circle your answer)
YES NO
If yes, please list any treatment, including the name of the physician treating you and any medications you are currently using (prescription, over the counter, or herbal):____________________________________
_____________________________________________________________________________________
Do you develop skin rashes in reaction to _____Food or _____Environment?
If yes, please list any know foods or environmental factors that produce rashes:______________________
______________________________________________________________________________________
List any other diseases or conditions:________________________________________________________
List any surgical procedures you have had in the last 6 months:___________________________________
______________________________________________________________________________________
Social History: (circle your answer)
Do you drink alcohol? YES NO
Do you use IV drugs? YES NO
Do you smoke? YES NO
Do you “dip” or “chew” YES NO
If yes, __________drinks per day.
If yes, what?_________How much?_____
If yes, _________packs per day.
If yes, what?_________How much?______
Do you have AIDS or have you ever been exposed to HIV(AIDS)? YES NO
Do you bleed easily? YES NO
(Women)Are you pregnant or breastfeeding? YES NO
What is your occupation?_________________________________________________________________
What are your hobbies?___________________________________________________________________
Forms completed by:
________Patient
________Medical Assistant________________
Initials
_______Nurse__________________________
Initials
________________________________________ ____________________________________
Patient or Guardian signature Date Reviewed by Date