mitchellderm.com - medical information

Mitchell Dermatology Medical Information
Patient Name *

First Name Last Name
Age *
Occupation *
Reason for your visit today *
Marital Status *
Pharmacy Name *
Pharmacy Phone Number
Please enter a valid phone number.
Pharmacy Location *
Do you take current medications *

Yes No
If "Yes" List current medications *
Do you have Current Allergies to medication? *

Yes No
If "Yes" List Current Allergies *
Do you occasionally use
Motrin/other NSAIDS *

Yes No
Aspirin/ Blood Thinners *

Yes No
Birth Control *

Yes No
Itching Pills *

Yes No
Allergy Pills *

Yes No
Social History
Pregnant *

Yes No
Nursing *

Yes No
Do you smoke cigarettes *

Yes No
Have you ever smoked *

Yes No
Do you use alcohol *

Yes No
How Frequently *
Do you have Major medical problems? *

Yes No
If "Yes" List Major medical problems *
Do you have Recent Surgery or Illness? *

Yes No
List Recent Surgery / Illness *
Do you have any of these conditions (Select all that apply) *

Asthma Diabetes High Blood Pressure Depression Hypothyroid Bleeding Tendencies AIDS / HIV Pacemaker Artificial Valve/ Joint Hepatitis Lung Disease Acid Reflux Low Blood Pressure Anxiety Hyperthyroid Migraines Stomach Ulcers Chrohn’s Disease Irritable bowel Syndrome Seasonal Allergies None
Do you have any other current skin concerns: (i.e sun spots, skin tags, Wrinkles) *

Yes No
If Yes please explain: *
Skin Cancer History
Have you ever had a mole removed? *

Yes No
If Yes diagnosis *
Have you ever had skin cancer? *

Yes No
Diagnosis *
If yes, type *

Basal Cell Carcinoma Squamous Cell Carcinoma Melanoma None
Do you use a sunscreen? *

Yes No
Type? *
(currently use)
SPF *
Do you use a tanning bed *

Yes No
Do you lay out in the sun *

Yes No
Have you ever sunburned *

Yes No
Do you have any of the following *

Abnormal Moles Dry Skin Eczema Itchy Skin Rash Scars Cold sores Acne Sensitive skin Hives Psoriasis Rosacea Sores that won’t heal Redness None
Do you have an interest in the following *

Botox Dysport Restylane Microneedling Juvederm Voluma Radiesse Coolsculpting Chemical Peels Anti-aging treatments None Other
Family History
Has any family member had skin cancer or melanoma? *

Yes No
Who? *
Has any family member had eczema or psoriasis? *

Yes No
Who? *
Please list all skin care products you *
Patient Signature *

Clear
Patient Name *

First Name Last Name
Date *

Month Day Year
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Mitchell Dermatology Medical Information

Do you occasionally use

Social History

Skin Cancer History

Family History