Patient History

Date:

Name:

DOB:

Current Medications & Supplements: Include Name and Dosage

Medication Allergies:

Other Allergies & Intolerances:

Do you have any history of a bleeding disorder?

Y N

Have you ever had an adverse reaction to anesthesia?

Y N

Dermatologic History

Acne

Past

Present

Never

Actinic Keratoses

Past

Present

Never

Atypical/Dysplastic

Past

Present

Never

Basal Cell Skin Cancer

Past

Present

Never

Blistering Sunburns

Past

Present

Never

Eczema

Past

Present

Never

Melanoma

Past

Present

Never

Psoriasis

Past

Present

Never

Shingles

Past

Present

Never

Squamous Cell Skin Cancer

Past

Present

Never

Use of Accutane

Past

Present

Never

Medical History

Asthma

Past

Present

Never

Anemia

Past

Present

Never

Arthritis

Past

Present

Never

Cancer

Past

Present

Never

Chicken pox

Past

Present

Never

Chronic Lung Disease

Past

Present

Never

Cirrhosis

Past

Present

Never

COPD

Past

Present

Never

Diabetes

Past

Present

Never

Epilepsy

Past

Present

Never

Glaucoma

Past

Present

Never

Heart murmur

Past

Present

Never

Hepatitis

Past

Present

Never

High Blood Pressure

Past

Present

Never

High Cholesterol

Past

Present

Never

HIV

Past

Present

Never

HPV/Warts

Past

Present

Never

HSV/Herpes

Past

Present

Never

IBS

Past

Present

Never

Multiple Sclerosis

Past

Present

Never

Myasthenia Gravis

Past

Present

Never

Pacemaker

Past

Present

Never

Pneumonia

Past

Present

Never

Rheumatic Fever

Past

Present

Never

Stroke

Past

Present

Never

Thyroid disease

Past

Present

Never

Tuberculosis

Past

Present

Never

Ulcers

Past

Present

Never

Other Injuries or Illnesses:

Social History

Smoking

Yes No

If Yes, How many packs per day

Years?

Alcohol

Yes No

If Yes, How many drinks per day?

Drinks per week?

Drug Use

Yes No

If Yes, What type?

Frequency

Daily Sunscreen

Yes No

SPF Strength:

Do you tan in a tanning bed?

Yes No

Frequency:

Have you ever tanned in a tanning bed?

Yes No

Years

Family History

Melanoma

Yes No

If Yes, which Relative(s)?

Basal Cell Skin Cancer

Yes No

If Yes, which Relative(s)?

Squamous Cell Skin Cancer

Yes No

If Yes, which Relative(s)?

Other Cancers

Yes No

Type:

Women Only

Are you pregnant?

Yes No

If Yes, How many weeks?

Are you trying to conceive?

Yes No

Are you breastfeeding?

Yes No

Are you using Birth Control?

Yes No

If Yes, What kind?

Operations/ Hospitalizations

Add more operations/hospitalizations

Cosmetic (Optional)

Are you interested in cosmetic treatments? – If yes, select all that apply:

Botox

Laser Hair Removal

Skin Tightening

Filler

IPL/ Photo facial

Microdermabrasion

Skin Care Products

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