NEW PATIENT MEDICAL INFORMATION
Patient Name:_______________________________________________________________________________
Reason for Visit:_____________________________________________________________________________
Past Medical History
Height_________ Weight_______
List any medical conditions:___________________________________________________________________
List known allergies to medications:____________________________________________________________
What medications do you take?:________________________________________________________________
For women: Are you pregnant?__________________ Breast Feeding?_______________________________
Do you have a personal history of skin cancer, atypical moles, or precancerous skin growths?:________
If “yes” what type:___________________________________________________________________________
Any history of chronic skin rashes (such as eczema, psoriasis, acne)?
_______________________________
If “yes” please describe:_______________________________________________________________________
Family History
Family history of skin cancer?:_____If “yes” please provide details ________________________________
Any family history of chronic skin conditions?:__________________________________________________
If “yes” please describe:_______________________________________________________________________
Social History
Do you smoke tobacco?______ Do you drink more than 10 alcoholic drinks per week?_______________
Are you exposed to the sun during your workday? _______ Do you use daily facial sunscreen?_______
Would you describe your past sun exposure as: Low_______
Moderate_______
High__________
Current Symptoms : (Check all that apply)
_____ Fever
_____ Chills
_____ Muscle w eakness
_____ Changes in heart rate
_____ Stomach upset
_____ Genitourinary symptoms
_____ Swelling of feet, ankle, or hands
_____ Blurring or other changes in vision
_____ Hay fever symptoms
_____ Changes in your hair or nails
_____ Anxiety or depression
_____ Shortness of breath or wheezing
_____ Joint pains
_____ Easy bruising
_____ Seizures
_____ Headaches
_____ Rash, itching
_____ Sore Throat
Signature of Patient:_________________________________________________ Date:____________________
For Staff: Reviewed by:______________________________________Date:______________________________