Patient History Form - English - Dermatology Sonoma & Santa Rosa

Name:

DOB:

Past Medical History

Anxiety

Arthritis

Asthma

Cancer

Depression

High Blood Pressure

HIV/AIDS

High Cholesterol

Hyperthyroidism

Hypothyroidism

Diabetes

Hepatitis

Acne

Actinic Keratosis

Basal Cell Skin Cancer

Eczema

Flaking or Itchy Scalp

Melanoma

Psoriasis

Squamous cell skin cancer

Other

None

Type of Diabetes:

Type of Cancer:

Type of Hepatitis:

If Other, Please specify:

Family History of Melanoma:

Yes No

Relatives:

Do you wear sunscreen daily?

Yes No

SPF:

Do you have a pacemaker?

Yes No

Have you received your flu shot?

Yes No

Have you received your pneumonia vaccine?

Yes No

Do you have a health care proxy in the event you are unable to make your own medical decisions?

Yes No

List of Medications:

None

Add another medication

Allergies to Medications:

No Known Allergies

Add another allergy

Social History

Tobacco/Nicotine User:

Current Former Never

If current, would you like to receive information on how to quit?

Yes No

Alcohol Use:

Less than 1 drink 1-2 drinks per day 3+ more drinks Never

Female Patients Only:

Are you currently pregnant?

Yes No

Breastfeeding?

Yes No

Expecting to be pregnant?

Yes No

History of Polycystic Ovarian Disease?

Yes No