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FROMM DERMATOLOGY MEDICAL HISTORY FORM PATIENT’S NAME: TODAY’S DATE: PREFERRED NAME: ___________________ DATE OF BIRTH: SEX: PRIMARY CARE PROVIDER: REFERRING PHYSICIAN (If applicable): OCCUPATION: EMAIL (optional):____________________________________ Are you interested in receiving e-mail notifications regarding special events on our cosmetic services & products? YES 1. NO Briefly describe the problem (with skin, hair, or nails) that brought you in today. 2. How long have you had this problem? 3. What treatments or medications have been tried for this problem? 4. Past Medical History: (please circle all that apply) Anxiety Depression Leukemia Arthritis Diabetes Lung Cancer Asthma End Stage Renal Disease Lymphoma Atrial fibrillation GERD Prostate Cancer Bone Marrow Hearing Loss Radiation Treatment Transplantation Hepatitis Seizures Breast Cancer High Blood pressure Stroke Colon Cancer HIV/AIDS COPD High Cholesterol NONE Coronary Artery Disease Thyroid Problems Other/Description_________________________________________________________________________ 5. Please list any surgeries you have had in the past and explain what for: ________________________________________________________________________ 6. Medications: (Please enter all current medications) ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ 7. Allergies: (Please enter all allergies) ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ 8. ALERTS: (please circle all that apply) Allergy to Adhesive Allergy to lidocaine Allergy to topical antibiotics Artificial heart valve Artificial joint replacement Blood thinners 9. Skin Disease History: (please circle all that apply) Acne Asthma Hay Fever/Allergies Dry Skin Eczema Defibrillator MRSA Pacemaker Require antibiotics prior to a surgical procedure Rapid heart beat with epinephrine Precancerous Moles Squamous Cell Skin Cancer Basal Cell Skin Cancer Melanoma Psoriasis Blistering Sunburns Flaking or Itchy Scalp Poison Ivy NONE Other___________________________________________________________________________________ 10. Do you wear Sunscreen? Yes 11. Do you tan in a tanning salon? No Yes If yes, what SPF? ___________ No 12. Social History: (Please circle all that apply) Cigarette Smoking: Alcohol Use: Currently Smokes Has smoked in the past Never smoked Former Smoker EtOH- None EtOH- less than 1 drink per day (socially) EtOH -1-2 drinks per day EtOH -3 or more drinks per day How many packs per day? ______ 13. FEMALE PATIENTS: a. Are you pregnant or currently trying to get pregnant? ____________________________ b. Breast feeding? c. Using hormone replacement therapy or using contraception containing hormones (birth control pills, Mirena IUP, Depo Provera)? If yes, please list: FAMILY HISTORY 1. Do you have a family history of Melanoma? Yes No If yes, which relative(s)? ________________________________________________________________ 2. Do you have a family history of autoimmune disease (such as lupus)? 3. Do you have a family history of eczema? ______ 4. Do you have a family history of psoriasis? ______
