Rachel Ness, MD, PLLC
Patient Health History Form
Patient Name: __________________________________________________Today’s Date: _______________________________________
Birth Date: __________________________________________ Date of Last Full Body Examination: _______________________________
What are you being seen for today? (We ask that you focus on 3 concerns per visit to enable Dr. Ness to provide the most thorough care)
1.
______________________________________________________________________________________________________
2.
______________________________________________________________________________________________________
3.
______________________________________________________________________________________________________
1. Have you ever had skin cancer?
Yes No
If yes, when, where on your body, and what type?
_____________________________________________________
2. Have any immediate relatives had skin cancer?
Yes No
If yes, who and what type?
_____________________________________________________
3. Do you have artificial joints, heart valves, pacemaker?
Yes No
If yes, where? ___________________________
4. Do you require pre-op antibiotics prior to any dental
procedures?
Yes No
5. Have you ever had a reaction to local anesthesia or
lidocaine/novocaine?
Yes No
If no, have you ever had local anesthesia? ___________________
6. (Women) Are you or could you be pregnant?
Yes No
7. Do you drink alcohol?
Yes No
How much? ____________________________
8. Do you smoke?
Yes No
How much? ____________________________
9. Do you use sunscreen?
Yes No
10. Have you ever had a blistering sunburn?
Yes No
11. Do you have any changing lesions or moles?
Yes No
12. Have you ever had an abnormal mole removed?
Yes No
If yes, when and where on your body?
_____________________________________________________
13. Do any 1st degree family members have seasonal allergies,
asthma, or atopic dermatitis?
Yes No
If yes, who? ____________________________
14. List any surgical procedures and approximate dates
below:
_____________________________________________________
_____________________________________________________
15. What is your occupation?
_____________________________________________________
Circle any conditions you currently have or have had in the past:
AIDS/HIV
Eczema or Atopic Dermatitis
Anemia
Environmental Allergies
Arthritis/Joint Deformity
Epilepsy
Asthma
Fainting
Bleeding Disorder/Blood Thinners
Glaucoma
Bowel Problems
Heart Attack
Cancer, what type? _________________
Heart Disease
Chest Pain
Heart Murmur
Chicken Pox
High Blood Pressure
Chronic Cough
Hepatitis
Depression
Herpes/Cold Sores
Diabetes
High Cholesterol
Irregular Heart Beat
Kidney Disease
Liver Disease
Lupus
Multiple Sclerosis
Pacemaker
Phlebitis
Psoriasis
Psychiatric Care
Seizures
Stroke
Thyroid Problems
List any other diseases or health conditions we should know about that are not included in the list above:
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
Medications currently taking (please include over the counter medications, supplements, vitamins, etc.)
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
Allergies to medications or latex:
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
Pharmacy Name and City: ________________________________________________
Pharmacy Phone: ___________________________________________