Midatlanticskinsurgery.com

MEDICAL HISTORY Today’s Date:______________
Name:________________________________________________________ Date of Birth:_____/______/__________
Height:_________________ Weight:________________ Primary Care Provider: ____________________________________
Reason for your visit today: ________________________________________________________________________________
Duration:__________________________ Location:_____________________________ Any Pets?: □ No □ Yes
Symptoms: _____________________________________________________________________________________________
Has this condition changed over time? □ No □ Yes If yes, how? _______________________________________________
Any past treatment? □ No □ Yes If yes, what treatment/medication?___________________________________
Any response to treatment? □ No □ Yes If yes, what? ______________________________________________________
Are you al ergic to any medications? □ No □ Yes If yes, list:
1.___________________________________ 2.________________________________ 3._______________________________
Reaction to allergy:
1.___________________________________ 2.________________________________ 3._______________________________
List al medications you are currently taking and dosage (follow-up patients: if any new medications, please list):
1.___________________________________ 2.________________________________ 3._______________________________
4.___________________________________ 5.________________________________ 6._______________________________
Do you now, or have you ever had any of the fol owing diseases or conditions? (Please check if self or family member)
List any surgeries you have had:
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Do you drink alcohol? □ No □ Yes If yes, ___________drinks per day
Do you bleed easily? □ No □ Yes
Do you smoke?
□ No □ Yes If yes, ___________packs per day For how many years? ___________________
Have you been exposed to HIV? □ No □ Yes Women, are you pregnant or nursing? □ No □ Yes
Have you ever had dental anesthesia (Xylocaine)? □ No □ Yes Any bad reaction? □ No □ Yes
When exposed to sun, do you: □ Tan Only □ Tan and Burn □ Burn Do you, or have you ever used a tanning bed? □ No □ Yes
Do you have a history of any specific skin diseases? □ No □ Yes If yes, please list: _________________________________
Preferred Pharmacy and location: _________________________________ Phone: ___________________________________
Patient/Guardian Signature_______________________________ Provider’s Signature: _______________________________

Source: http://www.midatlanticskinsurgery.com/documents/MedicalHistoryautofill.pdf