Medical History

Patient Name

DOB

Date

Primary Care Physician

Preferred Pharmacy

Reason For Visit – What is the reason for your visit today? How long has the condition been present?

PAST MEDICAL HISTORY - Do you have, or have ever been diagnosed with any of the following conditions: (Check if YES)

Other skin problems not listed above

UV Exposure – Check if YES

Uses sunblock > 30 SPF currently

History of blistering sunburn

Current use of tanning booth

History of tanning booth use

Vaccine Received – Check if YES, please include date.

COVID-19

Flu

Pneumonia

Tobacco Use – (if used one or more times within 24 months)

Yes

Alcohol Use

Yes

If yes, how many times in the past 12 months have you had (women 4, men 5) or more alcoholic beverages in a day?

Height and Weight

Height (in)

Weight (lbs)

Patient Medications – Current medications and over-the-counter (OTC) supplements

Patient Allergies – List any known allergies

For Women Only – Check if YES

Pregnant

Planning pregnancy

Nursing

MEDICAL HISTORY VERIFICATION

The information provided above is accurate and complete to the best of my knowledge.

Patient Initials

Date

Parent/Guardian Initials

Date

FOR OFFICE USE ONLY

PATIENT ID NUMBER

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