Reason for visit
Are you allergic to any medication? If yes, List:
List all medications you are currently taking:
Height and Weight
Do you have now, or have you ever had diseases or conditions of: (please check if so)
High Blood Pressure
Hepatitis or Yellow Skin
Convulsions, Epilepsy or Seizures
Do you drink alcohol?
If YES how many drinks per day?
Do you use IV drugs?
If YES, what do you use? and How much?
Have you had or have you been exposed to HIV (AIDS)?
Have you ever had dental anesthesia (novacaine)?
Any bad reactions to question above?
When you are exposed to the sun, do you:
Tan and Burn
Have you ever had skin cancer?
Has anyone in your family had skin cancer? If yes, who?
If you have any specific skin disease please list below:
List any other disease or condition we should know about:
List any surgical procedure you have had in the last 6 months:
Do you smoke
If you smoke, How much?
Do you bleed easy?
(Women) Are you pregnant?
Trying to become pregnant
Do you have artificial joints?
What is your occupation?
What are your hobbies?
Should be Empty: