Test Medical History Form

Past Medical History

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Today's Date*
Month
Day
Year
Name*
First Last
Birthdate*
Month
Day
Year
MD.
Primary Language
- English
- Arabic
- French
- German
- Mandarin
- Spanish
- Russian
Primary Pharmacy
PAST MEDICAL HISTORY
Adhesive tape allergy
- Yes
- No
Latex allergy
- Yes
- No
Local anesthetics allergy
- Yes
- No
Epinephrine sensitivity
- Yes
- No
Bacitracin allergy
- Yes
- No
Neosporin allergy
- Yes
- No
Anticoagulant treatment
- Yes
- No
Bleeding disorders
- Yes
- No
Artificial joint
- Yes
- No
Artificial heart valves
- Yes
- No
Pacemaker / defibrillator
- Yes
- No
Mitral valve prolapse
- Yes
- No
Immunosuppressed
- Yes
- No
Organ transplant
- Yes
- No
Cancer
- Yes
- No
Pre-op/pre-dental antibiotics
- Yes
- No
Memory problems
- Yes
- No
Fainting / syncope
- Yes
- No
Hepatitis or liver disease
- Yes
- No
HIV positive
- Yes
- No
Prior hospitalizations & surgery
- Yes
- No
Dates:
MRSA
- Yes
- No
Abdominal scars
- Yes
- No
Poor wound healing
- Yes
- No
HSV / cold sore
- Yes
- No
Eczema
- Yes
- No
Asthma
- Yes
- No
Hay fever
- Yes
- No
Heart disease
- Yes
- No
Diabetes
- Yes
- No
Kidney disease
- Yes
- No
Thyroid disease
- Yes
- No
Lupus
- Yes
- No
Arthritis
- Yes
- No
Psoriasis
- Yes
- No
High blood pressure
- Yes
- No
Seizure / epilepsy
- Yes
- No
Stomach ulcer / Intestinal
- Yes
- No
Glaucoma/eye disease
- Yes
- No
Tuberculosis/Lung disease
- Yes
- No
Venereal disease
- Yes
- No
Mole change color/shape/size
- Yes
- No
Other
MELANOMA HISTORY
Do you have a history of melanoma?
- Yes
- No
Date
Location
Do you have a history of skin cancer(s)?
- Yes
- No
If so, type
Date
Location
CURRENT MEDICATIONS
Including birth control, over the counter (OTC) or herbal medications
Medication
Dose
Medication
Dose
Medication
Dose
Medication
Dose
MEDICATION ALLERGIES
Do you have any medication allergies?
- Yes
- No
List allergies
FOR WOMEN ONLY
Are you pregnant?
- Yes
- No
Currently trying to conceive or planning a pregnancy?
- Yes
- No
Are you breastfeeding?
- Yes
- No
Do you have regular menstrual cycles?
- Yes
- No
Do you experience vaginal yeast infections?
- Yes
- No
FAMILY HISTORY OF MELANOMA
Do you have a family history of melanoma?
- Yes
- No
Do you have a family history of other skin cancer(s)?
- Yes
- No
SOCIAL HISTORY
Occupation:
Alcohol consumption?
- Socially
- Moderate
- Heavy
Do you use sunscreen?
- None
- Daily
- Occasionally
Tanning bed use?
- None
- Current
- Previous
ADDITIONAL SYMPTOMS
Fever
- Yes
- No
Chills
- Yes
- No
Fatigue
- Yes
- No
Unintentional weight loss
- Yes
- No
Eye Irritation
- Yes
- No
Chronic cough
- Yes
- No
Nausea / vomiting
- Yes
- No
Shortness of breath
- Yes
- No
Diarrhea
- Yes
- No
Abdominal pain
- Yes
- No
Constipation
- Yes
- No
Blood clots
- Yes
- No
Easy bruising
- Yes
- No
Swollen lymph nodes
- Yes
- No
Joint pain
- Yes
- No
Rash / itch
- Yes
- No
Headache
- Yes
- No
Anxiety
- Yes
- No
Depression
- Yes
- No
INTEREST IN COSMETIC PROCEDURES?
Botox
- Yes
- No
Wrinkle Therapy
- Yes
- No
Fillers
- Yes
- No
Blood vessel/spider vein destruction
- Yes
- No
Skin tag removal
- Yes
- No
Chemical peels
- Yes
- No

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Dermatology of Lower Manhattan

Test Medical History Form

Past Medical History