Medical History Form - Southview Dermatology

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Southview Dermatology Medical History Sheet

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.________________ 2._________________ 5._________________ 3.________________ 6.________________ 7.________________ 8._________________ 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 Bronchitis Emphysema Asthma Chronic Cough Morning Cough Wheezing Shortness of Breath Y Y Y Y Y Y Y N N N N N N N Diabetes Excessive thirst/hunger Thyroid Kidney Bladder Frequency/Burning Gastrointestinal/Stomach Y Y Y Y Y Y NO N N N N N N Cardiovascular: High Blood Pressure Chest Pain Heart Attack Heart Murmur Irregular Heartbeat Phlebitis YES Y Y Y Y Y Y NO N N N N N N absorptive disorder Nausea, vomiting, diarrhea when taking antibiotics Y Yeast infection when taking antibiotics Arthralgia Limited Motion Y Y Arthritis/Joint Deformity Y 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 Malignant Melanoma? Has anyone in your family had skin cancer? Malignant Melanoma? Artificial joint Convulsions, Epilepsy, or Seizures Fainting Tan only Yes Yes Yes Yes No No No No Y Y Y Tan and burn N N 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? Do you use IV drugs? YES YES Do you smoke? YES Do you “dip” or “chew” YES NO NO NO 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)? Do you bleed easily? YES NO 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

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