MEDICAL HISTORY
This is a confidential part of your treatment and will be kept in this office. Information included on this form will not be
released to anyone without written authorization from you.
DATE:_____________________
NAME: _________________________________________________________
DOB: _____________________
Is your general health good now?
BIRTHPLACE:_________________ Years in NM:____________________
Y
N
Date of your last physical exam:__________________________
(Last)
(First)
(Mi)
Name of Primary Care Physician _____________________________________________________________________
PERSONAL HISTORY OF ILLNESS
(circle all that apply)
Acne
Acid Reflux (GERD)
AIDS/HIV
Alopecia
Alzheimer’s Disease
Anemia
Anxiety
Arthritis
Asthma
Atrial Fibrillation (fast, irregular heart beat)
Bleeding Disorders _________________________________
Cancer Type: _________________________________
Congestive Heart Failure (CHF)
Crohn’s Disease/Ulcerative Colitis
Chronic Obstructive Pulmonary Disease (COPD)/Emphysema
Deep venous thrombosis (blood clot of the leg)
Dental Complications Type: __________________________
Depression
Diabetes Mellitus
Diverticulitis
Eczema
Glaucoma
Gout
Hayfever/Seasonal Allergies
Headaches
Heart Disease/Heart Attack (myocardial infarction)
Hepatitis Type:_____________________________________
Hives
Hypercholesterolemia (high)
Hypertension
Hyperthyroidism (high)
Hypothyroidism (low)
Irritable Bowel Syndrome (IBS)
Lymphoma/Leukemia Type: _____________________
Measles
Migraines
Parkinson’s Disease
Pulmonary Embolus (blood clot of the lung)
Psoriasis
Scarlet Fever
Seizures/Epilepsy
Sinus Problems
Skin Cancer (Melanoma, Basal Cell Carcinoma, Squamous Cell Carcinoma, Basosquamous Cell Carcinoma)
Other Skin Diseases Type: ___________________________
Stroke (TIA)
Sleep Apnea Use of CPAP device? Y N
Syphilis
Tuberculosis
Ulcers Where? ______________________
Varicella Zoster (Chicken Pox/Shingles)
Vertigo
Vitiligo
Warts Where? _______________________
Are you currently pregnant?
Y
N
Date of last pregnancy:___________________________________________
Are you currently under the care of a psychiatrist?
Y
N
If so, who is the doctor? ____________________________
SOCIAL HISTORY
Do you smoke tobacco products? Y
Do you drink alcoholic beverages?
N
Y
If yes, what kind and how much? ____________________________________
N
If yes, what kind, how much and how often?____________________________
Occupation: ____________________________________________________________________________________________
PAST SURGERIES (What kind and date):
______________________________________________________________________________________________________
PLEASE LIST ALL CURRENT MEDICATIONS (INCLUDING NON-PRESCRIPTION MEDICATIONS)
______________________________________________________________________________________________________
______________________________________________________________________________________________________
Do you require the use of coumadin (warfarin), aspirin, Plavix (clopidogrel), or Pradaxa (dabigatran etexilate)?
PLEASE LIST ANY DRUG ALLERGIES
_______________________________________________________________________________________________________
FAMILY HISTORY OF ILLNESSES
Has anyone in your immediate family ever had?
High Blood Pressure ________ Diabetes ________ Cancer ___________ Melanoma ________________ Acne __________
Skin Cancer _______Eczema _______ Psoriasis ________ Hayfever_________ Other, please explain:__________________
Health issues that interest you (please check all that apply)
_______ Botox Cosmetic
_______ Skin care advice/products/sunscreen
_______ Juvéderm, Restylane, Radiesse
_______ Skin rejuvenation/Prevage MD
_______ Hyperpigmentation
_______ Age spots
_______ Retin-A
_______ Microdermabrasion
_______ Chemical Peels/ alpha hydroxy acid/Glycolic peels
_______ Hair removal
_______ Spider vein treatment
_______ Laser treatments
_______ Eliminating underarm sweating
_______ Removing facial veins
_______ Latisse
_______ Other _____________________________________