Patient medical history

P A T I E N T M E D I C A L H I S T O R Y
Date ______________________________________________Refer ing Physician __________________________________________ Primary Care Physician _______________________________________Patient’s Name ___________________________________________________________ Date of Birth ______________________ Age ______Reason for today’s visit and prior treatments _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ PAST MEDICAL HISTORY: Please check al that apply and explain on reverse with dates if applicable.
URINARY SYSTEM
MUSCLES/RHEUMATOLOGIC
ENDOCRINE
NEUROLOGICAL SYSTEM
GI SYSTEM
IMMUNE SYSTEM
PSYCHOLOGICAL
INFECTIONS
GYNECOLOGIC
❑ Abnormal valve (mitral valve prolapse) PLEASE TURN PAGE TO CONTINUE →
Please briefly explain al of your medical problems including those listed on the front and any others: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Surgeries: ❑ Skin ❑ Other ______________________________________________________________________________________________ If you answered YES to skin cancer, please describe when, what type, and where on your body? _______________________________________________________________________________________________________________________________________________Do you have a history of sunburns (including during childhood)? ❑ Yes ❑ No MEDICATIONS: INCLUDING VITAMINS, OVER-THE-COUNTER DRUGS, HERBAL REMEDIES
_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Do you take blood thinners such as aspirin, Vitamin E, Plavix, Coumadin, or NSAIDS such as ibuprofen, naprosyn etc.? Please Circle.
Do you need to take antibiotics prior to dental work? (i.e. hip replacement, heart valve) ❑ Yes ❑ No D R U G A L L E R G I E S & T Y P E O F R E A C T I O N S
(i.e. swel ing/rash/nausea) ________________________________________________________________________________________________________________________________________________________________________________________________________ F A M I L Y M E D I C A L H I S T O R Y
Do your immediate family members have a history of skin cancer, “bad moles”, or other skin diseases (eczema, psoriasis, lupus, etc)?❑ Yes ❑ No If Yes, please explain: ______________________________________________________________________________________________________________________________________________________________________________________________ S O C I A L H I S T O R Y
Does (or did) your occupation require you to be primarily: ❑ Indoors ❑ Outdoors Occupation _____________________________Do you smoke? If Yes, packs per day? ______________________ # of years __________________ Do you cur ently use sunscreen? ❑ Yes ❑ No If Yes, what SPF? _________________________Do you wear hats? ❑ Yes ❑ NoRecreational activities ____________________________________________________________________________________________

Source: http://www.opderm.net/Forms/PatientMedHx.5.20.10.pdf