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DOHERTY DERMATOLOGY PATIENT HEALTH HISTORY INTAKE FORM Name: _______________________________________________________________ Date: _______________________ Preferred Pharmacy: _________________________________________________________________________________ Primary Care Physician: __________________________________Referred by: _________________________________ Past Medical History (Please circle all that apply and add detail if needed) Anxiety ___________________ Arthritis __________________ Atrial fibrillation ____________ Asthma ___________________ BPH ______________________ Bone marrow transplantation __________________________ Breast cancer ______________ Colon cancer _______________ Coronary artery disease ______ Depression __________________ Diabetes ____________________ End stage renal disease ________ GERD _______________________ Hearing loss __________________ Hepatitis _____________________ Hypertension _________________ HIV / AIDS ____________________ Hypercholestolemia ____________ Hyperthyroidism _______________ Hypothyroidism _______________ Lymphoma ____________________ Prostate Cancer ________________ Radiation Therapy _______________ Seizures _______________________ Stroke _________________________ Other, please specify: ____________ _______________________________ ARTIFICIAL JOINTS/VALVE:__________ PACEMAKER:____________________ DEFIBRILLATOR:___________________ ALLERGY ADHESIVE:_______________ ALLERGY LIDOCAINE:_______________ Past Surgical History (Please circle all that apply + YEAR) Appendix removed Joint replacement within last 2 years Bladder removed Kidney biopsy Mastectomy (R, L, and Bilateral) Kidney removed (R, L) Lumpectomy (R, L, Bilateral) Kidney stone removal Breast biopsy (R, L, Bilateral) Kidney transplant Breast reduction Ovaries removed: Endometriosis Breast implants Ovaries removed: Cyst Colectomy: Colon cancer resection Ovaries removed: Ovarian cancer Colectomy: Diverticulitis Prostate removed: Prostate cancer Colectomy: IBD Prostate biopsy Gallbladder removed TURP Coronary artery bypass Skin biopsy PTCA Basal cell cancer surgery Mechanical valve replacement Squamous cell carcinoma surgery Biological valve replacement Melanoma surgery Heart transplant Spleen removed Joint replacement, knee (R, L, Bi) Testicles removed (R, L, Bi) Joint replacement, hip (R, L, Bi) Hysterectomy: Fibroids Hysterectomy: Uterine cancer None Other, please specify: ________________________________________________________________________________ Please complete the front and back side of each page Skin Disease History (Please circle all that apply) Acne _________________________ Actinic Keratosis ________________ Asthma _______________________ Basal cell skin cancer ____________ Blistering sunburns ______________ Dry skin _______________________ Eczema ________________________ Other, please specify _____________ Flaking or itchy scalp _________________________ Hay fever / allergies __________________________ Melanoma __________________________________ Poison ivy ___________________________________ Precancerous moles ___________________________ Psoriasis ____________________________________ Squamous cell skin cancer ______________________ None of the above Do you wear sunscreen? Do you tan in a tanning salon? Yes _____ Yes _____ No _____ No _____ Do you have any known drug allergies? Yes No (please enter all allergies) _________________________ _________________________ _________________________ _________________________ _________________________ _________________________ Medications: Please enter all current medications with dosage, including topical, over-the-counter, and supplements _________________________ __________________________ __________________________ _________________________ __________________________ __________________________ _________________________ __________________________ None (Circle if taking none). Social History: Please circle all that apply Cigarette smoking: Never Quit/former smoker Smoke less than daily Illicit drug use: Never Drug use If yes, what? __________________________ When? _______________________ Alcohol use: None IV drug use Smokes daily How much? ______________________ Less than 1 drink a day 1-2 drinks a day 3 or more drinks a day Immediate Family Health History (mother, father, sister, brother). List family member condition and who it applies to below: MELANOMA ____________________________________________________ Psoriasis ____________________________________________________ Eczema ____________________________________________________ Stroke ____________________________________________________ Diabetes ____________________________________________________ Arthritis ____________________________________________________ Hypertension ____________________________________________________ Thyroid Disorder ____________________________________________________ Other: Condition:_______________________________ Family member: ________________ Please complete the front and back side of each page
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