Download Past Medical History: Please check all that apply Past Surgical

Medical History Form : PLEASE FILL OUT COMPLETELY
Name __________________________________________________________ D.O.B. _____________________________
Past Medical History: Please check all that apply
□ NO KNOWN MEDICAL HISTORY
□ Anxiety
□ Colon cancer
□ Hearing loss
□ Lung Cancer
□ Arthritis
□ COPD
□ Hepatitis
□ Lymphoma
□ High Cholesterol
□ Asthma
□ Coronary Artery
□ Multiple Sclerosis
□ Hypertension (high
□ Atrial fibrillation
Disease
□ Prostate cancer
blood pressure)
(irregular heartbeat)
□ Depression
□ Radiation treatment
□ HIV/AIDS
□ Bone Marrow
□ Diabetes
□ Seizures
□ Hyperthyroidism
Transplant
□ Diverticulitis
□ Stroke
□ Hypothyroidism
□ BPH
□ Renal disease
□ Leukemia
□ Breast Cancer
□ GERD (acid reflux)
□ Other ___________________________________________________________________________________________
Past Surgical History: Please check all that apply
□ NO SURGICAL HISTORY
□ Appendix Removed
□ Colon Resection
□ Joint replacement
□ Ovary Removed
□ Bladder removed
□ Coronary Artery
□ knee □ hip
□ Pacemaker
□ Mastectomy
bypass surgery
□ shoulder
□ Prostate Removed
□ R □ L □ Both
□ Defibrillator
Year: ________
□ PTCA (angioplasty)
□ Lumpectomy
□ Gallbladder removed
□ Kidney biopsy
□ Spleen Removed
□ R □ L □ Both
□ Heart Transplant
□ Kidney removal
□ Stents
□ Breast Biopsy
□ Heart Valve
□ Kidney Stone
□ Testicles removed
□ Breast Reduction
Replacement
removal
□ Breast Implants
□ Hysterectomy
□ Kidney Transplant
□ Other ____________________________________________________________________________________________
□ History of fainting with injections
Skin Disease History: Please check all that apply
□ NO SKIN DISEASE HISTORY
□ Acne
□ Dry Skin
□ Poison Ivy
□ Actinic Keratosis
□ Eczema
□ Precancerous Moles
□ Asthma
□ flaking or itchy scalp
□ Psoriasis
□ Basal Cell Skin Cancer
□ Hay fever/allergies
□ Squamous Cell Skin Cancer
□ Blistering Sunburns
□ Melanoma
□ Other _____________________________________________________________________________________________
□ Wears Daily Sunscreen. If yes, strength SPF: ____
Family History:
□ UNKNOWN / NONE
Medications: □ NONE
□ Non melanoma skin cancer
□ Melanoma
□ Psoriasis
□ Eczema
□ Auto immune disease
Please list all current with strengths if known OR provide receptionist with list
______________________________________________________________________________________________________
______________________________________________________________________________________________________
Pharmacy: _____________________________________
Allergies: Please list all drug allergies ______________________________________________________________________
□ NO KNOWN ALLERGIES □ Allergy to adhesive □ Allergy to latex □ Allergy to lidocaine □ Allergy to epinephrine
Social History: □ NO SOCIAL HISTORY □ Smokes tobacco- daily □ Smokes tobacco - not daily □ Has smoked in the past
□ Recreational drug use
□ Drinks alcohol- daily □ Drinks alcohol- not daily □ History of alcohol abuse
Baldone Reina Dermatology • 150 Lakeview Circle Covington LA 70433 • (985)892-3376 • www.baldonereinadermatology.com