Patient Medical History – Grand Strand Dermatology
Current Medications
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Medication Allergies (circle any)
Aspirin
Codiene
Erythromycin
Morphine
Penicillin
Sulfa Drugs
Tetracycline Others: ________________
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Who is your primary care physician? ____________________________________
Please Circle:
YES
NO
Do you have a history of malignant melanoma? If so provide dates and location.
YES
NO
Has anyone in your family had malignant melanoma? If so, whom?
YES
NO
Do you have a history of other skin cancers (basal or squamous cell)? If so, provide dates/location.
YES
NO
If you are a female patient, are you currently pregnant, planning pregnancy, or nursing?
Please list any previous surgeries, especially in the last 3 years:
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Review of Systems Please circle any you have experienced.
ALLERGIES
Food
Ointments
SKIN
Skin Cancer
Cold Sores
Genital Warts
Psoriasis
Eczema
Other:
GENERAL
Weight Loss
EAR, NOSE, MOUTH, THROAT
Creams
Lotions
Jewelry
Sexually Transmitted Disease
Cataracts
Glaucoma Macular Degeneration
Mouth Ulcers
Hay Fever
Nosebleeds
HEART, BLOOD VESSELS
High Blood Pressure
Heart Failure
LUNGS/CHEST
Asthma
GASTROINTESTINAL
Reflux Disease
KIDNEY/URINARY
Kidney Stone
GYNECOLOGY
Abnormal Menstrual Cycle
MUSCULOSKELETAL
Arthritis
NEUROLOGIC
Stroke
BLOOD
Anemia
ENDOCRINE
Thyroid Disease
Emphysema
Ulcers
Breast Cancer
Hearing Loss
Blood Clots
Tuberculosis
Gallbladder Disease
Prostate Infection
Paralysis
Angina
Lupus
Vertigo
Irregular Heartbeat
Pacemaker
Cold Sores
Heart Valve Disease
Lung Cancer
Inflammatory Bowel Disease
Bladder Infection
Frequent Sinusitis
Kidney Failure
Colitis
Pancreatitis
Prostate Cancer
Hepatitis
Prostate Disease
Polycystic Ovarian Disease
Seizures
Stinging/Burning Extremities
Bleeding or Clotting Disorder
Fainting
Multiple Sclerosis
HIV+
Diabetes
Social History Please circle
YES NO Do you smoke now?
YES NO Have you been a smoker?
YES NO Do you Consume Alcohol? How often? ______________
Family History Please advise on back of this form any family members with history of these medical problems: Asthma, Hay Fever, Eczema, Psoriasis,
Diabetes, Heart Disease, Melanoma, Lupus
Review Dates (Office Use Only) Medical history form was reviewed with patient and any changes added/dated in red ink on these dates (initial/date)
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Patient Name: ______________________________
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Date: ___________________