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Glenn H. Brown, M.D., PLLC Dermatology Medical History Patient Name: ____________________________________________________________Date Of Birth:_______/_______/_______Date:______/_____/______ Reason for today’s visit? _____________________________________________________________________________________________________________ How long have you had this problem?__________________________________________________________________________________________________ Is this a recurrent problem?__________________________________________________________________________________________________________ Where is the problem? ______________________________________________________________________________________________________________ Any symptoms? (bleeding, itching, etc.) ________________________________________________________________________________________________ Have you had any treatment for this problem? __________________________________________________________________________________________ Have you ever had a bad reaction to Lidocaine, Novacaine, or other topical anesthesia? NO ______ YES ______ Other _____________________________ List medications you currently take including Prescriptions, Over-The-Counter medications, ASPIRIN, Vitamins, Supplements, and Herbs: __________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________ NO ____ ____ Are you allergic to any medications? Have you ever had skin cancer? YES ____ ____ __________________________________________________________________ Type of Treatment: _________________________________________________ When? ___________________________________________________________ Where? ___________________________________________________________ Has anyone in your family had skin cancer? ____ ____ Type of skin cancer: ________________________________________________ Who? ____________________________________________________________ Do you have history of any specific skin diseases? ____ ____ Explain: __________________________________________________________ Have you had any surgical procedures? ____ ____ Explain: __________________________________________________________ Do you have any problems healing? ____ ____ Explain: __________________________________________________________ Do you develop Keloids (scars) after surgery? ____ ____ Explain: __________________________________________________________ Do you bleed easily? ____ ____ Explain: __________________________________________________________ Did you have childhood Eczema? ____ ____ Explain: __________________________________________________________ Do you need antibiotics before dental work? ____ ____ Explain: __________________________________________________________ Have you had organ transplant? ____ ____ Explain: __________________________________________________________ Have you had a stroke? ____ ____ Explain: __________________________________________________________ Have you had much sun exposures? ____ ____ Recreational_____ Occupational _____ Other______Explain: _____________ __________________________________________________________________________________________________________________________________ Do you develop Rashes in reaction to MEDICATIONS ___________________, FOOD ___________________, or ENVIRONMENT __________________ CURRENT OR PAST PROBLEMS Allergies Arthritis/ Gout Artificial Joints Asthma Blood Clots Cancer Cold Sores/ Fever Blisters Diabetes Eczema Eyes/Ears/Nose Gastrointestinal Headaches/Migraines Hay Fever Heart Disease Heart Murmur Self ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ Relative _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ Explain _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ _______________________ N N N N N N N Y Y Y Y Y Y Y High Blood Pressure HIV (AIDS) Hepatitis Intestinal Colitis Kidney(s)/ Liver Lung Disease Lupus Mitral Valve Prolapsed Neuropathy Pacemaker Psoriasis Psychiatric Disorders Seizures Thyroid Tuberculosis Self ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ Relative _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ Explain __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ __________________________ SOCIAL HISTORY Do you live alone? Do you smoke? Do you drink caffeine? Do you drink alcohol? Do you use recreation drugs WOMEN: Are you pregnant? Are you planning to be pregnant? How much? _________________________ How long? __________________________________ How much? _________________________ How long? __________________________________ How much? _________________________ How long? __________________________________ Type and Frequency: _____________________________________________________________ Due Date: _______________________________________________________________________ Employer/Occupation/Student: ________________________________________________ Hobbies: ______________________________________________ Patient, Parent, or Legal Guardian Signature: ______________________________________________________________ Date: _______/_______/_______ Reviewed by Glenn H. Brown, M.D. / Anngela Park, PA-C/ April Hofmann, PA-C: _______________________________ Date: _______/______/________
