Advanced Dermatology and Skin Surgery
MEDICAL HISTORY FORM
PATIENT to please fill out:
NAME: _________________________________________________ DATE: _________________ AGE: __________
REFERRED BY: (circle) SELF / FRIEND / YELLOW PAGES / DR. _____________________________________
ALLERGIES: (DRUG, SEASONAL, AND FOOD ALLERGIES) _________________________________________
PHARMACY NAME/LOCATION: _________________________________________________________________
PAST MEDICAL HISTORY: (Check the following medical conditions that you currently have)
 Anxiety
 COPD
 Hypercholesterolemia
 Arthritis
Coronary Artery Disease/Heart Disease
 Hyperthyroidism
Artificial Joints
 Depression
 Hypothyroidism
 Asthma
 Diabetes
 Leukemia
 Atrial Fibrillation (Irregular Heartbeat)  End Stage Renal Disease
 Lung Cancer
 BPH
 GERD
 Lymphoma
 Bone Marrow Transplantation
 Hearing Loss
 Pacemaker
 BPAP/CPAP
 Hepatitis
 Prostate Cancer
 Breast Cancer
 Hypertension
 Radiation Treatment
 Colon Cancer
 HIV / AIDS
 Seizures
 Other (Please List) ___________________________________________________
 Stroke
PAST SURGERIES:
 Appendix (Appendectomy)
 Heart: PTCA
 Ovaries: Ovarian Cancer
 Bladder (Cystectomy)
 Heart: Mechanical Valve Replacement
 Prostate: Prostate Cancer
 Breast: (Mastectomy) (Right/Left/Both)
 Heart: Bilogical Valve Replacement
 Prostate: Prostate Biopsy
 Breast: Lumpectomy (Right/Left/Both)
 Heart: Heart Transplant
 Prostate: TURP
 Breast: Breast Biopsy
 Joint Replacement: Knee (Rt or Lt or Both)  Skin: Skin Biopsy
 Breast: Reduction
 Joint Replacement: Hip (Rt or Lt or Both)  Skin: Basal Cell Carcinoma
 Breast: Implants
 Kidney: Kidney Biopsy
 Skin: Squamous Cell Carcinoma
 Colon (Colectomy): Colon Cancer Resection  Kidney: Nephrectomy
 Skin: Melanoma
 Colon (Colectomy): Diverticulitis
 Kidney: Kidney Stone Removal
 Spleen (Splenectomy)
 Colon (Colectomy): IBS
 Kidney: Kidney Transplant
 Testicles (Orchidectomy)
 Gallbladder (Cholecystectomy)
 Ovaries: Endometriosis
 Uterus (Hysterectomy): Fibroids
 Heart: Coronary Artery Bypass Surgery
 Ovaries: Ovarian Cyst
 Uterus (Hysterectomy)
 Other: ____________________________________________________________
Uterine Cancer
SKIN DISEASE HISTORY: Have you had any of the following skin conditions:
 Acne
 Dry Skin
 Poison Ivy
 Actinic Keratoses
 Eczema
 Precancerous Moles
 Asthma
 Flaking or Itchy Scalp
 Psoriasis
 Basal Cell Skin Cancer
 Hay Fever/Allergies
 Squamous Cell Skin Cancer
 Blistering Sunburns
 Melanoma
 Other: ____________________________________________________________________________________
Do you wear Sunscreen? Yes or No
If yes, what SPF? ____________
FAMILY HISTORY
Do you have a family history of Melanoma? Yes or No
 Mother
 Daughter
 Father
 Son
 Sister
 Uncle
 Brother
 Aunt
Do you tan in a tanning salon? Yes or No
If yes, which relative?
 Nephew
 Grandmother
 Niece
 Grandson
 Grandfather
 Granddaughter
 Other: __________________________________
SOCIAL HISTORY
Occupation: _______________________ Place of Employment:________________________________
If Retired: Previous Occupation:____________________________________________
Social History Details
 Sexually active with one partner
 Sexually active w/more than one partner
 Drug Use Type: ____________________
Caffeine Use:
 1 Cup/Day
 Several cups per day
Exercise:
 1 time per day
 Few times per week
REVIEW OF SYSTEMS:
Cardiovascular:
 Pacemaker
 Artificial Heart Valve
ENT, Mouth, Eyes:
 Sore Throat
Allergic / Immunologic:
 Premedication prior to procedures
 Allergy to lidocaine
Endocrine:
 Pregnant or planning a pregnancy
Constitutional / Symptom:
 Yeast infections w/antibiotics
 Unintentional Weight Loss
Gastrointestinal:
 GI Upset with Antibiotics
 Bloody Urine
Hematologic / Lymphatic:
 Problems with bleeding
Integumentary:
 Problems with Healing
 Changing Mole
Neurological:
 Headaches
Psychiatric:
 Anxiety
Musculoskeletal:
 Joint Aches
Respiratory:
 Cough
 Currently Smokes
 Smokes Every Day
 Has smoked in the past
 Smokes few times per week
 Never Smoked
 Few cups per week
 Never drinks coffee
 Few times per month
 Never Exercise
 Defibrillator
 artificial joints w/in past two years
 Rapid heartbeat with epinephrine  Chest Pain
 Blurry Vision
 Allergy to adhesive
 Immunosuppression
 Allergy to topical antibiotic ointments
 Hayfever
 Thyroid Problems
 Fever or Chills
 Night Sweats
 Abdominal Pain
 Bloody Stool
 Problems with scarring (hypertrophic or keloid)
 Rash
 Seizures
 Depression
 Muscle weakness
 Neck Stiffness
 Shortness of Breath
 Wheezing
OTHER REVIEW OF SYSTEMS:
ROS Notable For: __________________________________________________________________________________
__________________________________________________________________________________________________
 Allergic / Immunologic
 Cardiovascular
 Constitutional / Symptom
 Endocrine
 ENT and Mouth
 Eyes
 Gastrointestinal (G.I.)
 Genitourinary (G.U.)
 Hematologic / Lymphatic
 Integumentary
 Neurological
 Musculoskeletal
 Psychiatric
 Respiratory
PATIENT to please fill out:
Names of Medications (including aspirin, herbals, vitamins – DOSAGE NECESSARY):
Medication
Reason
Start Date
Stop Date
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MEDICAL STAFF TO FILL OUT:
SKIN CANCER HISTORY:
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Revised 1/13/14