Rockville Internal Medicine Group
DERMATOLOGY QUESTIONNAIRE
Printed Patient Name: ______________________________________________Date of Birth: _________________
REASON FOR VISIT: _________________________________________________Today’s Date: _________________
HOW DID YOU LEARN ABOUT US?
Primary Care Physician
Another Dermatologist
Family/Friend/Co-Worker
Other (Specify)
Referral Name
CURRENT MEDICATIONS: (Include Vitamins, Supplements, and over the counter medications)
Drug Name
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
MEDICATION ALLERGIES:
_____ No Known Allergies
Name of Medication
rash
rash
rash
rash
difficulty breathing
difficulty breathing
difficulty breathing
difficulty breathing
If yes, complete below:
Type of Reaction
stomach pain/vomiting
stomach pain/vomiting
stomach pain/vomiting
stomach pain/vomiting
other:
other:
other:
other:
MEDICAL HISTORY: PLEASE CHECK OR FILL IN ALL PHYSICIAN DIAGNOSED MEDICAL CONDITIONS
Skin Cancer:
Melanoma:
Date:
Location:
Squamous Cell Carcinoma:
Date:
Location:
Basal Cell Carcinoma:
Date:
Location:
Actinic Keratosis (pre-skin cancer):
Date:
Location:
Other:
Date:
Location:
Dermatological Disease:
Herpes/Cold Sores
Psoriasis
Eczema
Acne / Rosacea
Blistering disorder:
Healing Problems: slow keloid bruising
Hematology / Oncology:
Cancer; type:
Bleeding Problems
Immunological Disease:
Immune Deficiency
HIV / AIDS
Lupus or Scleroderma
Rheumatological Disease:
Osteoarthritis
Rheumatoid Arthritis
Gout
Psychological / Emotional Disease:
Depression
Obsessive / Compulsive
Gastrointestinal Disease:
Cron’s Disease, Ulcerative Colitis
Esophageal Reflux
Peptic Ulcer
Esophagitis
Cardiovascular Disease:
High Blood Pressure
Heart Problems:
Heart Attack: Date:
Pacemaker / AICD
Irregular Heart Beat
High Cholesterol
Endocrine Disease:
Diabetes
Hyperthyroid / Hypothyroid
Neurological Disease:
Stroke / Aneurysm
Seizure / Epilepsy
Alzheimer’s
Fainting
Kidney Disease:
Poor Functioning Kidneys
Dialysis: type:
For Female Patients:
Are you pregnant? YES NO
Are you Planning pregnancy? YES NO
Polycystic Ovarian Disease
Liver Disease:
Hepatitis: Type:
Jaundice
Lung Disease:
Asthma
COPD
Tuberculosis
Others: Not Listed:
SURGERIES:
Type of Surgery
Surgeon
Hospital
Date
FAMILY MEDICAL HISTORY: (PLEASE ADD ANY OTHERS NOT LISTED)
Conditions / Problems
Melanoma
Non-Melanoma Skin Cancer
Blistering Disorder
Auto-Immune Disorder
Psoriasis
Family Members affected and exact nature of problems
SOCIAL HISTORY / HABITS
Occupation: ______________________________ Active Retired
Smoker: Non-Smoker _____packs/day Quit Smoking in _______
Smokeless Tobacco: YES NO
Alcohol use: NO YES (# of drinks per week ______)
Recreational Drug Use: NO YES ___________________________________________
Sunscreen Use: Regularly Rarely Never
Outdoor Activity: _________________________________________________________
I have traveled outside the United States in the past three months: YES NO
TANNING / SUN EXPOSURE: (mark what describes you best – mark all that apply)
____ Always burn, never tan
____ Rarely Burn, Tan easily
____ Usually burn, tan with difficulty
____ At least 1 (one) blistering sunburn
____ Sometimes burn, usually tan
Have you ever used a tanning bed, If so, how often: ____________________ How many years:_______
Patient Printed Name: ________________________________________
DOB: _____________________
REVIEW OF SYMPTOMS: (Please mark all of the symptoms you’ve been having recently)
General
Weight Gain / Loss
Loss of appetite
Weakness
Fevers/Chills/Sweats
Skin
Skin Rash
Itching
Lumps
Dry/sensitive skin
Hives
Suspicious moles
Suspicious lesions
Jaundice
Acne
Hair loss
Ears/Nose/Throat
Congestion
Change in voice
Nose Bleeds
Drainage From Nose
Difficulty Swallowing
Hoarseness
Sore Throats
Headaches
Eyes
Decreased Vision
Eye Irritation
Eye Drainage
Blurry Vision
Endocrine
Excessive Sweating
Excessive Thirst
Excessive Urination
Heat Intolerance
Cold Intolerance
Cardiovascular
Swelling of Feet/Ankles
Musculoskeletal
Joint Pain/Swelling
Back Pain
Muscle Pains/Aches
Neck Pain
Leg Cramps
Joint Stiffness
Allergy
Runny nose
Scratchy throat
Itchy eyes
Sinus congestion
Sneezing
Hematology
Easy Bruising
Gastrointestinal
Nausea / Vomiting
Abdominal Pain
Change in Bowel Habits
Heartburn/Indigestion
Genitourinary
Pain with Urination
Frequent Urination
Blood / Lymph
Swollen Glands
Fatigue
Varicose Veins
Respiratory
Coughing
Wheezing
Congestion
Neurological
Numbness/Tingling
Headache
Seizures
Dizziness
Psychological
Depression
High Stress Level
Suicidal Thinking
Eating disorder
Mental or physical Abuse
Mood Swings
Obsessive-Compulsive Tendencies
Other Medical Problems Not Listed:
Patient Printed Name: ____________________________________________ DOB: _________________
Patient Signature: _________________________________________ Date: _______________________