Download Medical History Questionnaire

Medical History Questionnaire
Name:_____________________________________________________________ Date of Birth: _____/_____/________
The reason for your visit: _____________________________________________________________________________
How long has this been present? _________________What have you tried to treat it? ____________________________
Drug Allergies: ______________________________________________________________________________________
PERSONAL DERMATOLOGIC HISTORY
*Please check if you have a history of:
☐ Skin Cancer
Which Type?
☐ Melanoma - When? ______________ Location? ___________________
☐ Basal Cell Cancer - When? ______________ Location? ___________________
☐ Squamous Cell Cancer - When? ______________ Location? ___________________
☐ Actinic Keratosis (Precancerous Skin Growth)
☐ Eczema
☐ Psoriasis
☐ Lupus
☐ Scarring Acne
☐ Other dermatologic condition(s) ____________________________________________________________
MEDICAL HISTORY
*Please check if you have a history of:
☐ Allergies/Sinusitis
☐ Artificial Heart Valve
☐ Asthma
☐ Bleeding Disorder
☐ Cancer (other than skin cancer)
Which type? ______________
☐ Cataracts
☐ Cold Sores (Herpetic Infection)
☐ Congestive Heart Failure
☐ Depression
☐ Diabetes
☐ Diabetes Mellitus
☐ Emphysema/COPD
☐ Epilepsy
☐ GERD/(Reflux Disease)
☐ Glaucoma
☐ Heart Arrhythmia
☐ Heart Disease
☐ Hepatitis
☐ High Cholesterol
☐ HIV or AIDS
☐ Hypertension
☐ Irritable Bowel Syndrome
☐ Mitral Valve Prolapse
☐ Organ Transplant
☐ Osteoarthritis
☐ Osteoporosis
☐ Rheumatic Fever
☐ Rheumatoid Arthritis
☐ Stomach Ulcer
☐ Thyroid Disease
☐ Tuberculosis
☐ Other _______________________
SOCIAL HISTORY Do you wear sunscreen regularly? Yes No
Do you smoke? Yes No
FAMILY HISTORY
Use tanning beds? Yes No
Drink alcohol? Yes No Use drugs? Yes No
*Do any family members suffer from the following?
Condition:
Family Member (Relationship)
Skin Cancer (other than melanoma)
Melanoma
Asthma/Eczema/Seasonal Allergies
Psoriasis
For Women: Are you currently pregnant OR actively trying to get pregnant OR breastfeeding?
Are you interested in cosmetic products or procedures?
Have you had any cosmetic procedures in the past?
Yes
Yes
No
No
Yes
No
Anything specific? ________________________________
Were you happy with the results Yes
No