562

South Fair Oaks Ave.

PASADENA, CA 91105
626-123-4567

Dermatology Medical History

PT ACCOUNT #:

PATIENT NAME:

DATE OF BIRTH:

TODAYS DATE:

PATIENT EMAIL:

REASON FOR TODAYS VISIT:

REFERRING PHYSICIAN:

PHARMACY NAME:

PHARMACY PHONE:

PHARMACY ADDRESS:
ARE YOU ALLERGIC TO ANY MEDICATIONS? YES NO IF YES, PLEASE LIST BELOW:

HAVE YOU EVER HAD DENTAL ANESTHESIA (NOVOCAIN)? YES NO ANY BAD REACTION? YES NO

IF YES, PLEASEDESCRIBE:

DO YOU TAKE ASPIRIN (ANY DOSE, FOR ANY PURPOSE)? YES NO DO YOU TAKE PLAVIX? YES NO
DO YOU TAKE ANTIBIOTICS BEFORE DENTAL PROCEDURES? YES NO

PLEASE LIST ALL MEDICATIONS YOU CURRENTLY TAKE
(PRESCRIPTION, OVER THE COUNTER, VITAMINS, SUPPLEMENTS, HERBAL, etc.):

DO YOU CURRENTLY HAVE, OR HAVE YOU EVER HAD, ANY OF THESE DISEASES OR CONDITIONS? (Check Yes or No)
LUNGS
OTHER SYSTEMIC
Bronchitis (Chronic)
Asthma
Chronic Sinus Condition

Yes
Yes
Yes

No
No
No

CARDIOVASCULAR

Yes

No

Yes
Yes
Yes
Yes

No
No
No
No

High Blood Pressure

Mitral Valve Prolapse
Prosthetic Valve
Pacemaker
Defibrillator

Diabetes
Thyroid Condition
Kidney Dialysis
Kidney Transplant
Nausea, Vomiting, Diarrhea
When Taking Antibiotics
Yeast Infection When Taking
Antibiotics
Artificial Joint
Fainting with Needles or Blood

PLEASE LIST ANY OTHER DISEASES OR MEDICAL CONDITIONS:

Yes
Yes
Yes
Yes

No
No
No
No

Yes

No

Yes
Yes
Yes

No
No
No

PLEASE LIST ANY SURGICAL PROCEDURES YOU HAVE HAD IN THE LAST SIX MONTHS:

(PLEASE CONTINUE ON THE NEXT PAGE)

Dermatology Medical History, Continued

PT ACCOUNT #:

SKIN ISSUES

Have you ever had skin cancer?

Yes

No

Has Anyone in your family ever had skin cancer?

Yes

No

If so, whom?

Do you have a history of any specific skin disease?

Yes

No

Do you have problems with healing from injury or surgery?

Yes

No

Do you develop keloids (thickened or raised scars) after injury Yes

or surgery?

No

DO you bleed easily?

No

Yes

DO YOU DEVELOP SKIN RASHES IN REACTION TO ANY OF THE FOLLOWING? (Please check all that apply.)

Medications

Food

Topical Neosporin

Environment/Temperature

Bandages

Other

SOCIAL HISTORY
Do you drink alcohol? Yes No If YES, how many drinks per day?

Do you use IV drugs? Yes No If YES, what?

Do you smoke? Yes No If yes, how much?

Do you have or have you ever been exposed to HIV (AIDS)? Yes No

WHAT IS YOUR OCCUPATION?

ARE YOU PREGNANT? Yes No If YES, due date:

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Patient Signature

Date

Reviewed By

Date