Patient Information Form

Alabama Dermatology Associates

Please correct the errors described below.

Telephone #'s (including area code):

MEDICAL HISTORY

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Add another medical problem/condition:

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Add another previous surgery

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Add another skin disease:

Current Medications (including vitamins, supplements, herbals, over-the-counter, aspirin, and those for skin conditions)

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Add another medication

If yes, please list:

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Add another medication allergy

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