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PROVIDERS
PATIENT INFO
SERVICES
MEDICAL & SURGICAL
RESOURCES
DISEASES A-Z
ORGANIZATIONS
PROTECTIVE CLOTHING
EMPLOYMENT
BILL PAY
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Patient Medical Information
Name
*
Age
*
Date of Birth
*
Nature, location, and duration of your skin problem:
Previous treatments:
Are you currently having problems with any of the following?
Bleeding issues
Healing issues
Scarring issues
Rash
Immunosuppression
Hay Fever
Chest pains
Fever or chills
Night sweats
Unintentional weight loss
Thyroid problems
Sore throat
Blurry vision
Abdominal pain
Bloody stool
Bloody urine
Joint aches
Muscle weakness
Stiff neck
Headaches
Seizures
Cough
Shortness of breath
Wheezing
Anxiety
Depression
Past medical history:
None
Acid reflux
Anxiety
Arthritis
Artificial joints
Asthma
Atrial fibrillation
Benign Prostatic Hyperplasia
Breast cancer
Colon cancer
COPD (Emphysema)
Coronary artery disease
Depression
Diabetes
End stage renal disease
Hearing loss
Hepatitis A
Hepatitis B
Hepatitis C
High blood pressure
HIV/AIDS
High cholesterol
Hyperthyroidism
Hypothyroidism
Leukemia
Lung cancer
Lymphoma
Pacemaker
Prostate cancer
Radiation treatment
Seizures
Stroke
Valve replacement - heart
Year of joint replacement
Year of valve replacement
Other medical history:
Past surgical history:
None
Appendix
Bladder
Mastectomy right
Mastectomy left
Mastectomy bilateral
Lumpectomy right
Lumpectomy left
Lumpectomy bilateral
Breast biopsy right
Breast biopsy left
Breast biopsy bilateral
Colon
Gallbladder
Coronary artery bypass
Heart valve - mechanical
Heart valve - biological
Hysterectomy
Knee replacement - right
Knee replacement - left
Knee replacement -bilateral
Hip replacement - right
Hip replacement - left
Hip replacement -bilateral
Ovary removal
Prostate Biopsy/TURP
Other joint replacements in the last 2 years:
Years replaced:
Other surgeries:
Skin disease history:
None
Acne
Actinic Keratosis
Asthma
Basal cell skin cancer
Dry skin
Eczema
Flaking or itching scalp
Hay fever/allergies
Keloid
Melanoma
Poison ivy
Precancerous moles
Psoriasis
Squamous cell skin cancer
Other skin issues:
Have you had severe or blistering sunburns?
*
Yes
No
How many?
Do you wear sunscreen?
*
Yes
No
SPF:
Do you tan at a tanning salon?
*
Yes
No
Do you have a family history of melanoma?
*
Yes
No
List relatives and approximate age of diagnosis:
Current medications (dose & frequency, include prescription, OTC, vitamins, & supplements)
List medicines you're allergic to and specify reaction:
Cigarette use:
*
Never smoked
Former smoker
Smoke less than daily
Smoke daily
Alcohol use:
*
Yes
No
Number of drinks daily:
Family history;
Asthma
Cystic Acne
Diabetes
Eczema
High blood pressure
Keloids
Lupus
Psoriasis
Seasonal allergies
Tuberculosis
Heart disease
Skin cancer
Type
Female patients only:
Are you pregnant?
Yes
No
Are you presently nursing?
Yes
No
Do you plan on becoming pregnant in the next year?
Yes
No
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