Medical History
Name
First Name
Last Name
Reason for visit
Are you allergic to any medications? If yes, please list:
List all medications you are currently taking:
Height and Weight
-
H
W
Please check any/all condition(s)/disease(s) below that you have now or have had in the past:
Asthma
Artificial Joints
Artificial Heart Valve(s)
High Blood Pressure
Heart Disease
High Cholesterol
Pacemaker
Defibrillator
Cancer
Anxiety/Depression
Auto-Immune Problem(s)
HIV/AIDS Exposure
Diabetes
Thyroid Disease
Kidney Disease
Stomach Issues
Arthritis
Fainting
Surgery in the Last 6 Months
If you answered yes to any of the above, please explain:
Do you drink alcohol?
Yes
No
If YES how many drinks per day?
Do you smoke cigarettes, cigars or e-cigarettes?
Yes
No
If yes, which and how much?
Do you use any non-prescription drugs?
Yes
No
If YES, what do you use? How often?
Are you allergic to lidocaine or novocaine?
Yes
No
When you are exposed to the sun, do you:
Tan only
Tan and Burn
Burn
Have you ever had skin cancer?
Yes
No
Has anyone in your family had skin cancer? If yes, who?
If you have any specific skin disease please list:
List any other disease or condition we should know about:
(Women) Are you pregnant?
Yes
No
Trying to become pregnant
(Women) Are you nursing?
Yes
No
What is your occupation?
What are your hobbies?
Submit
Should be Empty: