Download Patient History - Park Avenue Dermatology

Park Avenue Dermatology
Patient Name______________________________________ Date__________________
Sex____M____F
Age_____
Height_____ Weight______
Are you allergic to any medications? ___yes ___no If yes please list below:
1.________________________
2._________________________
3.________________________
4._________________________
List ALL medications you are currently taking (including prescriptions, over the counter, vitamins, and
herbals):
1.________________
2._________________
3.________________
4.________________
5._________________
6.________________
7.________________
8._________________
9.________________
Do you have now, or have you ever had any of the following diseases or conditions:
(please circle Y for yes and N for no)
Lungs:
Bronchitis
Emphysema
Asthma
Chronic Cough
Morning Cough
Shortness of Breath
Wheezing
Cardiovascular:
High Blood Pressure
Chest Pain
Heart Attack
Heart Murmur
Irregular Heartbeat
Phlebitis
Inflammation of vein
Blood clots
Pacemaker
YES
NO
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
YES
Y
Y
Y
Y
Y
Y
Y
Y
NO
N
N
N
N
N
N
N
N
Y
N
Skin: (please circle your answer)
When you are exposed to sun do you:
Have you ever had skin cancer?
Malignant Melanoma?
Has anyone in your family had skin cancer?
Malignant Melanoma?
Other Systemic:
YES
Diabetes
Excessive thirst/hunger
Thyroid
Kidney
Bladder
Frequency/Burning
Gastrointestinal/Stomach
absorptive disorder
Nausea, vomiting, diarrhea
when taking antibiotics
Yeast infection when
taking antibiotics
Arthritis/Joint Deformity
Arthralgia
Limited Motion
Artificial joint
Convulsions, Epilepsy, or
Seizures
Fainting
Tan only
Yes
Yes
Yes
Yes
NO
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
Y
N
Y
N
Y
Y
Y
Y
Y
N
N
N
N
N
Y
Y
N
N
Tan and burn
No
No
No
No
Burn
If yes, who?____________________________________________________________________________
Do you have a history of any specific skin disease?
(please circle your answer)
YES
NO
If yes, please list:________________________________________________________________________
Are you currently receiving any treatment for any specific skin diseases?
YES
NO
(please circle your answer)
If yes, please list any treatment, including the name of the physician treating you and any medications you
are currently using (prescription, over the counter, or herbal):____________________________________
_____________________________________________________________________________________
Do you develop skin rashes in reaction to _____Food
or
_____Environment?
If yes, please list any know foods or environmental factors that produce rashes:______________________
______________________________________________________________________________________
List any other diseases or conditions:________________________________________________________
List any surgical procedures you have had in the last 6 months:___________________________________
______________________________________________________________________________________
Social History: (circle your answer)
Do you drink alcohol?
YES
NO
If yes, __________drinks per day.
Do you use IV drugs?
YES
NO
If yes, what?_________How much?_____
Do you smoke?
YES
NO
If yes, _________packs per day.
Do you “dip” or “chew” YES
NO
If yes, what?_________How much?______
Do you have AIDS or have you ever been exposed to HIV(AIDS)?
YES
NO
Do you bleed easily?
YES
NO
(Women)Are you pregnant or breastfeeding?
________________________________________
Patient or Guardian signature
Date
YES
NO
____________________________________
Reviewed by
Date