MEDICAL HISTORY
Name____________________________________________________
Date________________
Do you currently have any of the following conditions?
Anxiety
Depression
Hypothyroidism
Arthritis
Diabetes
Leukemia
Asthma
End Stage Renal Disease
Lung Cancer
Atrial Fibrillation (irregular heartbeat)
GERD
Lymphoma
BPH
Hearing Loss
Prostate Cancer
Bone Marrow Transplant
Hepatitis
Radiation Treatment
Breast Cancer
High Blood Pressure
Seizures
Colon Cancer
HIV/AIDS
Stroke
COPD
High Cholesterol
NONE
Coronary Artery Disease
Hyperthyroidism
Other:__________________________________________________________________________
Have you had any surgery on the following organs?
Appendix
Ovaries – Cancer
Heart – PTCA
Bladder
Ovaries – Cyst
Heart – Mechanical Valve Replacement
Breast – Lump R L
Prostate – Cancer
Heart – Transplant
Breast – Mastectomy R L
Prostate – Biopsy
Joint – Hip R L
Breast – Biopsy R L
Prostate – TURP
Joint – Knee R L
Breast – Reduction/Implant
Spleen
Kidney – Biopsy
Colon – Cancer
Testicles
Kidney – Removal
Colon – Diverticulitis
Uterus – Fibroids
Kidney – Stone Removal
Colon – Inflammatory Bowel Disease
Uterus – Cancer
Kidney – Biopsy
Gall Bladder
NONE
Ovaries – Endometriosis
Heart – Coronary Artery Bypass
Other:__________________________________________________________________________
MEDICAL HISTORY
Name____________________________________________________
Date________________
Have you had any of the following skin diseases? (please Circle)
Acne
Dry Skin
Poison Ivy
Actinic Keratoses -pre-cancers
Eczema
Precancerous Moles
Asthma
Flaking/Itching Scalp
Psoriasis
Basal Cell Skin Cancer
Hay Fever/Allergies
Squamous Cell Carcinoma
Blistering Sunburn
Melanoma
NONE
Other:__________________________________________________________________________
Do you use a sunscreen on a regular basis? YES
NO
What kind? ________________________________________________________________________
Do you currently use a tanning bed? YES
NO
How many times have you used a tanning bed? #______
Have you previously used a tanning bed, but currently do not? YES
NO
Do you have any family history of skin cancer? YES NO
What kind?
Basal Cell Carcinoma
Squamous Cell Carcinoma
Melanoma
What family member(s)?_____________________________________________________________
Please list all medications you are currently taking:
Please list any allergies you have to medications:
Social History:
Alcohol – none
Alcohol – less than 1 drink daily
Alcohol – 1-2 drinks daily
Alcohol – more than 3 drinks daily
What pharmacy do you use?
Current every day smoker
Current some day smoker
Former smoker
Never smoked
__________________________________________________