Dyson Dermatology
PLLC
NAME__________________________________DATE_____________
Past Medical History
___ Anxiety
___ Arthritis
___ Asthma
___ Atrial Fibrillation (Irregular Heartbeat)
___ BPH
___ Bone Marrow Transplantation
___ Breast Cancer
___ Colon Cancer
___ COPD
___ Coronary Artery Disease
___ Depression
___ Diabetes
___ End stage renal Disease
___GERD
___ None
___ Hearing Loss
___ Hepatitis
___ Hypertension
___ HIV/AIDS
___ Hypercholesterolemia
___ Hyperthyroidism
___ Hyporthyroidism
___ Leukemia
___ Lung Cancer
___ Lymphoma
___ Prostate Cancer
___ Radiation Treatment
___ Seizures
___ Stroke
___ Other ___________________________
Past Surgeries
___ Appendix (Appendectomy)
___ Bladder (Cystectomy)
___ Breast: Mastectomy (Right Breast)
___ Breast: Mastectomy (Left Breast)
___ Breast: Mastectomy (Both Breasts)
___ Breast: Lumpectomy (Right Breast)
___ Breast: Lumpectomy (Left Breast)
___ Breast: Lumpectomy (Both Breasts)
___ Breast: Breast Biopsy
___ Breast: Breast Reduction
___ Breast: Breast Implants
___ Colon (Colectomy): Colon Cancer Resection
___ Colon (Colectomy): Diverticulitis
___ Colon (Colectomy): Inflammatory Bowel Dis.
___ Gallbladder (Cholecystectomy)
___ Heart: Coronary Artery Bypass Surgery
___ Heart: PTCA
___ Heart: Mechanical Valve Replacement
___ Heart: Biological Valve Replacement
___ Joint Replacement: Knee (Both)
___ Joint Replacement: Hip (Right)
___ Joint Replacement: Hip (Left)
___ Joint Replacement: Hip (Both)
___ Kidney: Kidney Biopsy
___ Kidney: Nephrectomy
___ Kidney: Kidney Stone Removal
___ Kidney: Kidney Transplant
___ Ovaries (Oophorectomy): Endometriosis
___ Ovaries (Oophorectomy): Ovarian Cyst
___ Ovaries (Oophorectomy): Ovarian Cancer
___ Prostate (Prostatectomy): Prostate Cancer
___ Prostate (Prostatectomy): Prostate Biopsy
___ Prostate (Prostatectomy): TURP
___ Skin: Skin Biopsy
___ Skin: Basal Cell Carcinoma
___ Skin: Squamous Cell Carcinoma
___ Skin: Melanoma
___ Spleen (Splenectomy)
___ Heart: Heart Transplant
___ Joint Replacement: Knee (Right)
___ Joint Replacement: Knee (Left)
___ Testicles (Orchidectomy)
___ Uterus (Hysterectomy): Fibroids
___ Uterus (Hysterectomy): Uterine Cancer
___ None
Skin Disease History
___ Acne
___ Actinic Keratoses
___ Asthma
___ Basal Cell Skin Cancer
___ Blistering Sunburns
___ Dry Skin
___ Eczema
___ Flaking or Itchy Scalp
___ Hay Fever/Allergies
___ Melanoma
___ Poison Ivy
___ Precancerous Moles
___ Psoriasis
___ Squamous Cell Skin Cancer
___ None
___ Other ___________________________
Do you wear Sunscreen?
Yes ___ No ___
If yes, what SPF?
Do you tan in a tanning salon?
Yes ___ No ___
Family History
Do you have a family history of Melanoma?
Yes ___ No ___
If yes, which relative?
___ Mother
___ Father
___ Sister
___ Brother
___ Daughter
___ Son
___ Uncle
___ Aunt
___ Nephew
___ Niece
___ Grandmother
___ Grandfather
___ Grandson
___ Granddaughter
Medications
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Allergies
____________________________________________________________________
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Social History
___ Alcohol none
___ Alcohol less than 1 drink per day
___ Alcohol 1-2 drinks per day
___ Alcohol 3 or more drinks per day
___ Current everyday smoker
___ Current someday smoker
___ Former smoker
___ Never smoker
___ None
Review of systems
Problems with bleeding
Hematologic/Lymphatic
Yes
___
No
___
Problems with healing
Integumentary
___
___
Problems with scarring
(Hypertrophic or Keloid)
Integumentary
___
___
Rash
Integumentary
___
___
Thyroid problems
Endocrine
___
___
Immunosuppression
Allergic/Immunologic
___
___
Hay fever
Allergic/Immunologic
___
___
Fever or chills
Constitutional/Symptom
___
___
Night sweats
Constitutional/Symptom
___
___
Unintentional weight loss
Constitutional/Symptom
___
___
Sore throat
ENT and Mouth
___
___
Blurry vision
Eyes
___
___
Abdominal pain
Gastrointestinal (GI)
___
___
Bloody urine
Genitourinary (GU)
___
___
Joint aches
Musculoskeletal
___
___
Muscle weakness
Musculoskeletal
___
___
Headaches
Neurological
___
___
Seizures
Neurological
___
___
Cough
Respiratory
___
___
Shortness of breath
Respiratory
___
___
Anxiety
Psychiatric
___
___
Depression
Psychiatric
___
___