Advanced Dermatology and Skin Surgery

Advanced Dermatology and Skin Surgery

MEDICAL HISTORY FORM

PATIENT to please fill out:

NAME: ______DATE: ______BIRTHDATE:___/___/___

REFERRED BY:______

LIST OF CURRENT DR. & SPECIALISTS ______

ALLERGIES: (DRUG, SEASONAL, AND FOOD ALLERGIES) ______

PHARMACY NAME/LOCATION: ______

MEDICAL HISTORY:(Check the following medical conditions that you currently have)

AnxietyDepressionLeukemia

Arthritis Diabetes Lung Cancer

AsthmaEnd Stage Renal DiseaseLymphoma

 Atrial Fibrillation(Irregular Heartbeat) GERD (Reflux Disease)  Pacemaker/Defibrillator

Bone Marrow Transplantation Hearing Loss Prostate Cancer

 BPH(Benign Prostatic Hyperplasia) Hepatitis Radiation Treatment

Breast Cancer Hypertension (High BloodPressure)Seizures

Colon CancerHypercholesterolemia(High Cholesterol)Stroke/TIA

 Pulmonary Disease/COPD HIV / AIDS

Coronary Artery Disease/Heart DiseaseHyperthyroidism

Hypothyroidism

 Other (Please List) ______

PAST SURGERIES:

 Appendix (Appendectomy)  Heart: Transplant Prostate: Prostate Cancer

 Bladder (Cystectomy)  Joint Replacement Knee Date:____R or L  Prostate: Prostate Biopsy

Breast: (Mastectomy)  Joint Replacement Hip Date:____R or L  Prostate: TURP

 Breast: Lumpectomy (Right/Left/Both)  Kidney: Kidney Biopsy Rectum: Rectal Resection APR

 Breast: Breast Biopsy  Kidney: Kidney Nephrectomy Rectum: Rectal Resection

 Colon (Colectomy) Colon Cancer Resection  Kidney: Kidney Stone Removal Skin: Skin Biopsy

 Colon (Colectomy) Diverticulitis  Kidney: Kidney Transplant Skin: Basal Cell Carcinoma

 Colon (Colectomy): IBS  Liver: Liver Transplant Skin: Squamous Cell Carcinoma

 Colon Colostomy  Liver: Liver Shunt or Hepatectomy Skin: Melanoma

 Gallbladder (Cholecysectomy)  Ovaries: Endometriosis Spleen: (Spenectomy)

 Heart: Coronary Artery Bypass Surgery  Ovaries: Ovarian Cyst Testicles: (Orchidectomy)

 Heart: PTCA  Ovaries: Ovarian Cancer  Uterus(Hysterectomy):Uterine Cancer

 Heart Mechanical Valve Replacement  Ovaries: Tubal Ligation  Uterus(Hysterectomy):Cervical Cancer

 Heart: Bilogical Valve Replacement  Pancreas: PancreatectomyUterus(Hysterectomy):Fibroids

Other______

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 NoIf yes, what SPF? ______Do you tan in a tanning salon? Yes or No

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FAMILY HISTORY:

Do you have a family history of Melanoma? Yes or No If yes, which relative?______

Do you have a family history of:

Autoimmune Disorder Carcinoma: Basal Cell Carcinoma: Squamous cell

Diabetes Eczema Psoriasis Hair Loss Hay fever/Asthma Other Cancer/Malignancy

(Please mark which relative & listed condition)

 Mother______Daughter______Nephew______ Grandmother______

Father______Son______Niece______ Grandson______

Sister______Uncle______Grandfather______ Granddaughter______

 Brother______Aunt______ Other: ______

SOCIAL HISTORY:

Occupation: ______Place of Employment:______

If Retired: Previous Occupation:______

Social History Details

 Currently Smokes  Has smoked in the past  Smokes Every Day  Never Smoked  Smokes few times per week

 Drug/Alcohol Use Type: ______How Often?______

Exercise:

 1 time per day  Few times per week  Few times per month  Never Exercise

REVIEW OF SYSTEMS:

Cardiovascular:

 Pacemaker Defibrillator Artificial joints w/in past two years

 Artificial Heart Valve Rapid heartbeat with epinephrine Chest Pain

Allergic / Immunologic:

 Premedication prior to procedures Allergy to adhesive Allergy to topical antibiotic ointments

 Allergy to lidocaine Immunosuppression

Endocrine:Constitutional / Symptom:

 Pregnant or planning a pregnancy Yeast infections w/antibiotics  Fever or Chills  Unintentional Weight Loss

Gastrointestinal:Hematologic / Lymphatic:

 GI Upset with Antibiotics  Problems with bleeding

Integumentary/Skin:

 Problems with Healing Problems with scarring (hypertrophic or keloid)

 Changing Mole Rash

PATIENT to please fill out:

Please provide your complete list of Current Medications (including aspirin, herbals, vitamins – DOSAGE NECESSARY):

Medication Dosage Reason

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