Advanced Dermatology and Skin Care Specialist
DERMATOLOGIC HISTORY
NAME______________________________________________________AGE___________DATE__________________

Are you allergic to any prescription or non-prescription (pill or rub-on)? If Yes, Please give name(s):

Please list all Medications you are currently taking (including vitamins, herbals, etc.):

Pleas list surgical procedures you have had in the past 6 months:
Past Medical History

Do you have a history of any of the following? IF Yes, Please X.
NAME________________________________________________________________________________
Abnormal scarring or keloids
Eczema (also called atopic dermatitis)
Malignant Melanoma
Pre-cancerous growths
Psoriasis
Skin Cancer Specify________________
_________________________________
_________________________________
Heart Value Replacement
Joint Replacement
High Blood Pressure
Kidney disease
Liver disease
Pacemaker
Thyroid Disease
Diabetes
Arthritis
Depression
Lupus
Asthma
Heart Attack
Hepatitis
Other_________________
Congestive Heart Failure
Family History

NAME________________________________________________________________________________
Do
you have a blood relative with any of the following? If Yes, Please X.
Malignant Melanoma
Arthritis
Hair Loss
Abnormal moles
Asthma
Vitilgo
Skin Cancer
Heart Disease
Rosacea
Pre-cancerous growths
High cholesterol
Eczema (atopic dermatitis)
Depression or suicide attempt(s)
Psoriasis
Cancer
Diabetes
Other____________________________
Social History










Do
you use tobacco?
Yes
No If yes, what type and how much?_________________________________
NAME________________________________________________________________________________
Are you ____________single, ______________married, ______________divorced, _______________widowed?
Do you drink alcohol?
Yes
No If yes, how much in one week? __________________________________
Do you use recreational drugs?
Yes
No If yes, what type and how much?
Do you use IV drugs
Yes
No If yes, what type and how much?___________________________
Have you ever been exposed to HIV (AIDS)?
Yes
No
Do you have hepatitis?
Yes
No
Have you ever had dental anesthesia (Novocaine)?
Yes
No Any bad reaction?
Yes
No
Do you need Antibiotics before dental work?
Yes
No
What type of work do you do? _______________________________________________________________
Review of Systems




NAME________________________________________________________________________________
Skin
type: ___________ Normal, ____________Oily, ______________Dry,_______________ Combination
Is your skin easily irritated?
Yes
No
Do you tan easily, ___________ always burn, ______________ or are you somewhere in the middle? _______
Do you use sunscreens/sunblocks?
Yes
No If yes, how often_________ what SPF? _______________
Do you ever experience any of the following?
Abdominal pain
Easy Bruising/Bleeding
Headaches
Muscle pain/weakness
Palpitations
Vaginal Discharge
Depression
Fever
Heartburn
Nausea/Vomiting
Penile Discharge
Vision Problems
Dry Eyes
Frequent Infections
Heat/Cold Intolerance
Night Sweats
Red Eyes
Weight Change
Dry Mouth
Hair Loss
Joint pain or swelling



Do you wear contacts?
Yes
No
Do you have a dental plate?
Yes
No
Do you have artificial joints
Yes
No




For Females:
Date of your last menstrual period?_____________________
Are your periods regular? Yes
No
What type of contraception (if any) is used? ________________________________
Do you have problems with unwanted hair?
Yes
No If yes, where____________________
Completed by
Patient
Medical Assistant_______
_____________________________________________
Signed by Physician
Date
_____________________________________________
Reviewed by
Date