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                                                 MEDICAL HISTORY

 

Patient:_______________________________________________________     Date:____________________________

 

Reason for today’s visit: _____________________________________________________________________________

 

Are you allergic to any medications?  YES  NO   If yes, list:__________________________________________________

 

List all Medications you are currently taking:______________________________________________________________

_________________________________________________________________________________________________

 

Significant Past or Current Health Problems: _____________________________________________________________

_________________________________________________________________________________________________

 

Women Only:

On birth control pills?              YES         NO           Other contraceptive                                YES         NO

Are you Pregnant?                  YES         NO           Due Date:____________________

Do you have Endometriosis    YES         NO

 

Do you  have now, or have you ever had diseases or conditions of:  (Please circle  YES or NO)

 

Lungs:     Other Systemic:    
Bronchitis YES NO Diabetes YES NO
Emphysema YES NO

Thyroid

 YES NO 
Asthma YES NO Kidney YES NO 
Chronic Cough YES NO Bladder YES NO
Morning Cough YES NO Bowel YES NO
      Hepatitis or Yellow Skin YES NO
Vascular:     Glaucoma YES NO
High Blood Pressure YES NO Arthritis/Joint Deformity YES NO
Chest Pain YES NO  Convulsions, Epilepsy or Seizures YES NO
Heart Attack  YES  NO  Fainting YES NO
Heart Murmur YES  NO  Headaches YES NO
Irregular Heartbeat  YES  NO       
Pacemaker  YES  NO       
Phlebitis  YES  NO       
           

Who is your primary care Doctor/Pediatrician/Internist?_______________________________________

 

PreferredPharmacy:_________________________________________________________________________________

 

Skin:

When you are exposed  to sun do you:                                  Tan Only                     Tan & Burn         Burn

 

Have you ever had skin cancer?  (Please Circle)                  YES         NO

Has anyone in your family had skin cancer?                          YES         NO           If yes, Who?_____________________

Do you  have any history of any specific skin diseases?      YES         NO

 

If yes, please list: __________________________________________________________________________________

 

SKIN EXAMINATION

Nl

See Note

Area of skin examined

 

 

Head/Face

 

 

Neck

 

 

Chest, Breast, Axilla

 

 

Back

 

 

Abdomen

 

 

Upper Extremities R & L

 

 

Lower Extremities R & L

 

 

Genitalia, Groin, Buttocks

                                                                               

__________________________________________________

                                                                                  Signed by Physician                                  Date

 

__________________________________________________

                                                                                            Dates Reviewed
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